Healthcare Provider Details

I. General information

NPI: 1063197812
Provider Name (Legal Business Name): JALEN K LUTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 BLANDING ST
COLUMBIA SC
29201-3520
US

IV. Provider business mailing address

4615 FOREST DR APT 521
COLUMBIA SC
29206-3181
US

V. Phone/Fax

Practice location:
  • Phone: 180-325-6410
  • Fax:
Mailing address:
  • Phone: 256-682-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31439
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: