Healthcare Provider Details

I. General information

NPI: 1912400300
Provider Name (Legal Business Name): CAROLINA CARDIOLOGY AND VASCULAR ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WELLNESS BLVD STE 106
IRMO SC
29063-2872
US

IV. Provider business mailing address

1 WELLNESS BLVD STE 106
IRMO SC
29063-2872
US

V. Phone/Fax

Practice location:
  • Phone: 803-888-2282
  • Fax:
Mailing address:
  • Phone: 180-388-8228
  • Fax: 803-888-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number17456
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number17456
License Number StateSC

VIII. Authorized Official

Name: DANIEL P BOUKNIGHT
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 803-888-2282