Healthcare Provider Details

I. General information

NPI: 1467871335
Provider Name (Legal Business Name): CONSTANCE MARIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 PAGELAND HWY
LANCASTER SC
29720-7606
US

IV. Provider business mailing address

1833 PAGELAND HWY
LANCASTER SC
29720-7606
US

V. Phone/Fax

Practice location:
  • Phone: 803-286-9948
  • Fax: 803-286-5418
Mailing address:
  • Phone: 803-286-9948
  • Fax: 806-286-5418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number108361
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number108361
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: