Healthcare Provider Details

I. General information

NPI: 1588434245
Provider Name (Legal Business Name): LIBERTY DOCTORS LLC DBA EBB TIDE COMPREHENSIVE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 MARINA DR STE A2
CHARLESTON SC
29492-7573
US

IV. Provider business mailing address

669 MARINA DR STE A
CHARLESTON SC
29492-7542
US

V. Phone/Fax

Practice location:
  • Phone: 843-491-9955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name: CHELSEY DEVER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 843-225-8320