Healthcare Provider Details

I. General information

NPI: 1821317363
Provider Name (Legal Business Name): BONSAIN COMPLETE WOMEN'S HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 PLANTATION PARK DR STE 204
BLUFFTON SC
29910-9008
US

IV. Provider business mailing address

29 PLANTATION PARK DR STE 204
BLUFFTON SC
29910-9008
US

V. Phone/Fax

Practice location:
  • Phone: 843-715-0570
  • Fax:
Mailing address:
  • Phone: 843-715-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number30791
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number30791
License Number StateSC

VIII. Authorized Official

Name: MS. STACEY MARIE BARTLOW
Title or Position: BILLING
Credential:
Phone: 843-684-5501