Healthcare Provider Details

I. General information

NPI: 1497734271
Provider Name (Legal Business Name): SOUTHERN CLINIC AND URGT CAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 FILBERT HWY
CLOVER SC
29710-5602
US

IV. Provider business mailing address

PO BOX 550490
GASTONIA NC
28055-0490
US

V. Phone/Fax

Practice location:
  • Phone: 803-222-0600
  • Fax: 803-222-6119
Mailing address:
  • Phone: 704-865-2755
  • Fax: 704-865-5013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AUGUSTINE R EZE
Title or Position: PRESIDENT
Credential: MD
Phone: 704-865-2755