1396161808 NPI number — SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396161808 NPI number — SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396161808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRMO
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29063-0026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-240-5399
Provider Business Mailing Address Fax Number:
803-791-1634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1494 LAKE MURRAY BLVD
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212-8697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-240-5399
Provider Business Practice Location Address Fax Number:
803-791-1634
Provider Enumeration Date:
03/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GRAY
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE COMPLIANCE OFFICER
Authorized Official Telephone Number:
803-240-5399

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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