1700134186 NPI number — LOWCOUNTRY NEUROPATHY OF HILTON HEAD, LLC

Table of content: (NPI 1700134186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700134186 NPI number — LOWCOUNTRY NEUROPATHY OF HILTON HEAD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOWCOUNTRY NEUROPATHY OF HILTON HEAD, 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:
1700134186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 FLYNN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29405-6784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-817-7404
Provider Business Mailing Address Fax Number:
843-529-0234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55A SHERIDAN PARK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-6025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-817-7404
Provider Business Practice Location Address Fax Number:
843-529-0234
Provider Enumeration Date:
08/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LUCKIE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
843-817-7404

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23765 , 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: 1427030212 . This is a "PROVIDER NPI" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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