Healthcare Provider Details

I. General information

NPI: 1679594261
Provider Name (Legal Business Name): CAROLINA FACIAL PLASTIC SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 GREGG AVE
FLORENCE SC
29501-4120
US

IV. Provider business mailing address

1714 GREGG AVE
FLORENCE SC
29501-4120
US

V. Phone/Fax

Practice location:
  • Phone: 843-665-0400
  • Fax: 843-667-8487
Mailing address:
  • Phone: 843-665-0400
  • Fax: 843-667-8487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number16126
License Number StateSC

VIII. Authorized Official

Name: DR. CARLA CAMILLE GRAHAM
Title or Position: PRACTICE OWNER
Credential: MD
Phone: 843-665-0400