1497295174 NPI number — THE PEDIATRIC CARE CENTER, LLC

Table of content: (NPI 1497295174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497295174 NPI number — THE PEDIATRIC CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PEDIATRIC CARE CENTER, 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:
1497295174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6614 AUGUSTA HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29070-9213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-604-8400
Provider Business Mailing Address Fax Number:
803-604-8404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6614 AUGUSTA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29070-9213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-604-8400
Provider Business Practice Location Address Fax Number:
803-604-8404
Provider Enumeration Date:
03/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
803-604-8400

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  21070 , 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)





Copyright © 2007-2025 www.npivalidator.com