Healthcare Provider Details

I. General information

NPI: 1891218939
Provider Name (Legal Business Name): MARIGRACE VANDEVENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-5037
  • Fax: 843-347-1541
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number226954
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: