Healthcare Provider Details

I. General information

NPI: 1558738344
Provider Name (Legal Business Name): CAROLINA INTEGRATED MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 CHARLOTTE HWY
FORT MILL SC
29707-7587
US

IV. Provider business mailing address

8451 CHARLOTTE HWY
FORT MILL SC
29707-7587
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-8114
  • Fax:
Mailing address:
  • Phone: 803-548-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3709
License Number StateSC

VIII. Authorized Official

Name: RYAN VALENCIC
Title or Position: PRESIDENT
Credential:
Phone: 814-233-9387