Basic Information
| Provider Information | |||||||||
| NPI: | 1750580304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARTANIAN | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN BSN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 TAYLOR STREET SUITE 4-E | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032968906 | ||||||||
| FaxNumber: | 8032968908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 TAYLOR STREET SUITE 4-E | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032968906 | ||||||||
| FaxNumber: | 8032968908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R51777 | SC | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | R51777 | 01 | SC | STATE RN LICENSE | OTHER |