Healthcare Provider Details

I. General information

NPI: 1922511658
Provider Name (Legal Business Name): CAROLINA HEALTHCHOICE OF COLUMBIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1494 LAKE MURRAY BLVD
COLUMBIA SC
29212-8697
US

IV. Provider business mailing address

1494 LAKE MURRAY BLVD
COLUMBIA SC
29212-8697
US

V. Phone/Fax

Practice location:
  • Phone: 803-764-0464
  • Fax: 803-764-3126
Mailing address:
  • Phone: 803-764-0464
  • Fax: 803-764-3126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES SLOAN
Title or Position: CFO
Credential:
Phone: 803-764-0464