Healthcare Provider Details

I. General information

NPI: 1548889280
Provider Name (Legal Business Name): SALT MARSH HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CHESTERTON CT
BLUFFTON SC
29910-7332
US

IV. Provider business mailing address

21 CHESTERTON CT
BLUFFTON SC
29910-7332
US

V. Phone/Fax

Practice location:
  • Phone: 314-616-8114
  • Fax:
Mailing address:
  • Phone: 314-616-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRENDA M THEILEN
Title or Position: ADULT NURSE PRACTITIONER
Credential: MSN, APRN, ANP-BC
Phone: 314-616-8114