Healthcare Provider Details

I. General information

NPI: 1174412787
Provider Name (Legal Business Name): MARQUIS CENTER OF CHARLESTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 TOBIAS GADSON BLVD STE 200
CHARLESTON SC
29407-4925
US

IV. Provider business mailing address

4447 N CENTRAL EXPY STE 110
DALLAS TX
75205-4246
US

V. Phone/Fax

Practice location:
  • Phone: 618-402-6622
  • Fax:
Mailing address:
  • Phone: 618-402-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLARK A PETERSEN
Title or Position: DIRECTOR OF INFRASTRUCTURE
Credential:
Phone: 618-402-6622