Healthcare Provider Details

I. General information

NPI: 1265258388
Provider Name (Legal Business Name): EMILY CISEWSKI MLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE RM 318
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

6893 SHAHID ROW
NORTH CHARLESTON SC
29418-3563
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-5711
  • Fax:
Mailing address:
  • Phone: 843-751-7598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: