Healthcare Provider Details

I. General information

NPI: 1124547617
Provider Name (Legal Business Name): SOUTHEASTERN ANESTHESIA ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WELLNESS BLVD STE 111
IRMO SC
29063-2873
US

IV. Provider business mailing address

550 ROSE SHARON DR
LEXINGTON SC
29072-7669
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-3770
  • Fax:
Mailing address:
  • Phone: 803-917-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LORETTA RICARD NOLES
Title or Position: OWNER
Credential:
Phone: 803-917-1684