Healthcare Provider Details

I. General information

NPI: 1770809428
Provider Name (Legal Business Name): SOUTHEASTERN EAR NOSE THROAT ALLERGY AND SLEEP DISORDERS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 03/07/2023
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 PINNACLE POINT DR
COLUMBIA SC
29223-5735
US

IV. Provider business mailing address

1040 PINNACLE POINT DR
COLUMBIA SC
29223-5735
US

V. Phone/Fax

Practice location:
  • Phone: 803-509-7200
  • Fax: 803-509-7213
Mailing address:
  • Phone: 803-509-7200
  • Fax: 803-509-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number28760
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number28760
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number28760
License Number StateSC

VIII. Authorized Official

Name: DR. CHAD B GUNNLAUGSSON
Title or Position: OWNER
Credential: MD
Phone: 803-509-7200