1730752015 NPI number — ANGELIC PRIMARY MEDICINE OF SC, LLC

Table of content: (NPI 1730752015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730752015 NPI number — ANGELIC PRIMARY MEDICINE OF SC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELIC PRIMARY MEDICINE OF SC, 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:
1730752015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8025 BLACK HORSE PIKE STE 501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLEASANTVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08232-2967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-822-7979
Provider Business Mailing Address Fax Number:
609-822-7980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
923B MEDICAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29572-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
854-444-9998
Provider Business Practice Location Address Fax Number:
843-353-2495
Provider Enumeration Date:
07/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
609-464-1135

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24726 . This is a "LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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