Healthcare Provider Details

I. General information

NPI: 1528143922
Provider Name (Legal Business Name): MIDLANDS ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WELLNESS BLVD SUITE 111
IRMO SC
29063
US

IV. Provider business mailing address

1 WELLNESS BLVD STE 111 MIDLANDS ENDOSCOPY CENTER, LLC
IRMO SC
29063-2873
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-3770
  • Fax: 803-749-3558
Mailing address:
  • Phone: 803-749-3770
  • Fax: 803-749-3558

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: REBECCA SUZETTE STONE
Title or Position: ADMINISTRATOR
Credential:
Phone: 803-749-3770