Healthcare Provider Details

I. General information

NPI: 1396161808
Provider Name (Legal Business Name): SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1494 LAKE MURRAY BLVD 1ST FLOOR
COLUMBIA SC
29212-8697
US

IV. Provider business mailing address

PO BOX 26
IRMO SC
29063-0026
US

V. Phone/Fax

Practice location:
  • Phone: 803-240-5399
  • Fax: 803-791-1634
Mailing address:
  • Phone: 803-240-5399
  • Fax: 803-791-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENN GRAY
Title or Position: CORPORATE COMPLIANCE OFFICER
Credential:
Phone: 803-240-5399