Basic Information
| Provider Information | |||||||||
| NPI: | 1396290995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEGGETT TIVA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4860 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8434914023 | ||||||||
| Practice Location | |||||||||
| Address1: | 4731 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295765090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438397246 | ||||||||
| FaxNumber: | 8434914023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2016 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | RAEDORD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8438600324 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2255 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.