1669981429 NPI number — SOUTH CAROLINA CENTER FOR INTERGRATIVE MEDICINE

Table of content: (NPI 1669981429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669981429 NPI number — SOUTH CAROLINA CENTER FOR INTERGRATIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CAROLINA CENTER FOR INTERGRATIVE MEDICINE
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:
1669981429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
612 SAINT ANDREWS RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29210-5120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-386-8684
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
612 ST ANDREWS RD.
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-386-8684
Provider Business Practice Location Address Fax Number:
803-386-8684
Provider Enumeration Date:
09/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SHIRK
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSCIAN ASSISTANT
Authorized Official Telephone Number:
803-386-8684

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2504 , 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: 1164683926 . This is a "COMMERCIAL" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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