Healthcare Provider Details

I. General information

NPI: 1639422892
Provider Name (Legal Business Name): THE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 WILLIAM HILTON PKWY
HILTON HEAD ISLAND SC
29926-5218
US

IV. Provider business mailing address

157 WILLIAM HILTON PKWY
HILTON HEAD ISLAND SC
29926-5218
US

V. Phone/Fax

Practice location:
  • Phone: 843-681-8260
  • Fax:
Mailing address:
  • Phone: 843-681-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberA1897
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberP1897
License Number StateSC

VIII. Authorized Official

Name: MR. GIUSEPPE BALIN DEABATE
Title or Position: OWNER
Credential: APRN
Phone: 843-338-1337