Basic Information
| Provider Information | |||||||||
| NPI: | 1447420815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINUTECLINIC DIAGNOSTIC SOUTH CAROLINA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 772 | ||||||||
| Address2: | MINUTECLINIC CREDENTIALING | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028950784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4014063539 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296806708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | 4014063539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | PINCINCE | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4017703813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | DO3831 | 01 | SC | MEDICARE RAILROAD | OTHER |