1518302108 NPI number — IMC OF SOUTH CAROLINA

Table of content: (NPI 1518302108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518302108 NPI number — IMC OF SOUTH CAROLINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMC OF SOUTH CAROLINA
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:
1518302108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2615 CENTENNIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-0586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-656-1837
Provider Business Mailing Address Fax Number:
850-877-2917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 HWY 76
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-656-1837
Provider Business Practice Location Address Fax Number:
850-877-2917
Provider Enumeration Date:
05/08/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ATKINSON
Authorized Official First Name:
TARA
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
INSURANCE & BILLING COORDINATOR
Authorized Official Telephone Number:
850-656-1837

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  6662 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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