Healthcare Provider Details

I. General information

NPI: 1851883714
Provider Name (Legal Business Name): CALBA ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 ROBERT SMALLS PKWY
BEAUFORT SC
29906-4237
US

IV. Provider business mailing address

630 HIGHLAND ST
ORANGEBURG SC
29115-4357
US

V. Phone/Fax

Practice location:
  • Phone: 803-747-8235
  • Fax:
Mailing address:
  • Phone: 803-747-8235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHY BAGLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 843-606-6776