1184027617 NPI number — PRS 5, LLC

Table of content: (NPI 1184027617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184027617 NPI number — PRS 5, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRS 5, 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:
6
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:
1184027617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-2397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-235-0200
Provider Business Mailing Address Fax Number:
843-235-0242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2676 CHURCH ST
Provider Second Line Business Practice Location Address:
UNIT D-2
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-4471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-733-3031
Provider Business Practice Location Address Fax Number:
843-279-0189
Provider Enumeration Date:
09/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KINMARTIN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
843-235-0200

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3690 , 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)





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