1972859684 NPI number — NICOLE MARIE SCHWEDE DPT

Table of content: NICOLE MARIE SCHWEDE DPT (NPI 1972859684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972859684 NPI number — NICOLE MARIE SCHWEDE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHWEDE
Provider First Name:
NICOLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
NICOLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972859684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530062
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30353-0062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-695-6071
Provider Business Mailing Address Fax Number:
843-569-5879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4340 LADSON RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-376-5056
Provider Business Practice Location Address Fax Number:
843-376-2730
Provider Enumeration Date:
07/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  8108 , 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)

  • Identifier: TH3589 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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