1245590140 NPI number — SOURCE DIAGNOSTICS OF SOUTH CAROLINA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245590140 NPI number — SOURCE DIAGNOSTICS OF SOUTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOURCE DIAGNOSTICS OF SOUTH CAROLINA, 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:
1245590140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5275 NAIMAN PKWY
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
SOLON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44139-1029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-645-7822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2701 S OCEAN BLVD
Provider Second Line Business Practice Location Address:
UNIT 1831
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-4641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-645-7822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BARRY
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
440-645-7822

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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