Healthcare Provider Details

I. General information

NPI: 1891442869
Provider Name (Legal Business Name): SOUTHCOAST SPINE AND PAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SOCIETY HILL DR STE 202
AIKEN SC
29803-1755
US

IV. Provider business mailing address

440 SOCIETY HILL DR STE 202
AIKEN SC
29803-1755
US

V. Phone/Fax

Practice location:
  • Phone: 803-226-0102
  • Fax: 803-226-0384
Mailing address:
  • Phone: 803-226-0102
  • Fax: 803-226-0384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DARYAN LONG
Title or Position: BILLING MANAGER
Credential:
Phone: 843-224-8086