1033593454 NPI number — KERSHAW CLINICS LLC

Table of content: JOSEPH PATRICK CARRILLO N.P. (NPI 1154780328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033593454 NPI number — KERSHAW CLINICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KERSHAW CLINICS 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:
1033593454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1165 HIGHWAY 1 S
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LUGOFF
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29078-8966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-438-0872
Provider Business Mailing Address Fax Number:
803-438-4391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 PINNACLE PKWY
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29045-8390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-424-5165
Provider Business Practice Location Address Fax Number:
803-424-5174
Provider Enumeration Date:
07/15/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESTEP
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
615-764-3000

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , 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)