1023545316 NPI number — MAIN HEALTHCARE LLC

Table of content: (NPI 1023545316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023545316 NPI number — MAIN HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN HEALTHCARE 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:
1023545316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1454 GENTRY MEMORIAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASLEY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29640-6940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-644-2700
Provider Business Mailing Address Fax Number:
864-644-2710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERAW
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29520-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-537-8200
Provider Business Practice Location Address Fax Number:
843-537-8444
Provider Enumeration Date:
05/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING ADMINISTRATOR
Authorized Official Telephone Number:
864-644-2700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4068 , 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: 4068 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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