1497184667 NPI number — CHARLESTON ENT ASSOCIATES 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 1497184667 NPI number — CHARLESTON ENT ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLESTON ENT ASSOCIATES 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:
CHARLESTON ENT SMP
Provider Other Organization Name Type Code:
5
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:
1497184667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2295 HENRY TECKLENBURG DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29414-7801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-793-6402
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 WINGO WAY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-216-8774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VECCHIOLLA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
843-793-6402

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  22628 , 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)