1700263886 NPI number — GOOSE CREEK IMAGINING, 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 1700263886 NPI number — GOOSE CREEK IMAGINING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOSE CREEK IMAGINING, 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:
1700263886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOOSE CREEK
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29445-1120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-553-5235
Provider Business Mailing Address Fax Number:
843-797-8189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BERKELEY SQUARE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOOSE CREEK
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29445-2958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-553-5235
Provider Business Practice Location Address Fax Number:
843-797-8189
Provider Enumeration Date:
04/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BARGANIER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-553-5235

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZX9317 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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