Healthcare Provider Details

I. General information

NPI: 1194144493
Provider Name (Legal Business Name): CHARLESTON FACIAL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 BROAD ST SUITE 200
CHARLESTON SC
29401-2936
US

IV. Provider business mailing address

281 E SHORE LN
CHARLESTON SC
29407-5656
US

V. Phone/Fax

Practice location:
  • Phone: 843-882-7181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberTL36529
License Number StateSC

VIII. Authorized Official

Name: DR. DAVID WASTSON RODWELL III
Title or Position: OWNER
Credential: M.D.
Phone: 843-882-7181