1356582597 NPI number — LOWCOUNTRY SPINE & SPORT, LLC

Table of content: (NPI 1356582597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356582597 NPI number — LOWCOUNTRY SPINE & SPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOWCOUNTRY SPINE & SPORT, 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:
1356582597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 NEW RIVER PKWY
Provider Second Line Business Mailing Address:
BUILDING 2, SUITE 37
Provider Business Mailing Address City Name:
HARDEEVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29927-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 NEW RIVER PKWY
Provider Second Line Business Practice Location Address:
BUILDING 2, SUITE 37
Provider Business Practice Location Address City Name:
HARDEEVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29927-4450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-422-0781
Provider Business Practice Location Address Fax Number:
800-210-2452
Provider Enumeration Date:
03/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BATSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-422-0781

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  22310 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 22310 , 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: 223109 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com