Healthcare Provider Details

I. General information

NPI: 1508189838
Provider Name (Legal Business Name): DERMATOLOGY AND LASER CENTER OF CHARLESTON/PALMETTO STATE PHARM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2093 HENRY TECKLENBURG DR SUITE 300
CHARLESTON SC
29414-5741
US

IV. Provider business mailing address

2000 SAM RITTENBERG BLVD SUITE 3009
CHARLESTON SC
29407-4629
US

V. Phone/Fax

Practice location:
  • Phone: 843-556-8886
  • Fax: 888-318-5567
Mailing address:
  • Phone: 843-769-7633
  • Fax: 888-318-5567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number19977
License Number StateSC

VIII. Authorized Official

Name: JENNIFER KNAPP
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 843-408-4171