Healthcare Provider Details

I. General information

NPI: 1730596685
Provider Name (Legal Business Name): ATLANTIC DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2237 HIGHWAY 9 E
LONGS SC
29568-5701
US

IV. Provider business mailing address

2237 HIGHWAY 9 E
LONGS SC
29568-5701
US

V. Phone/Fax

Practice location:
  • Phone: 843-399-9965
  • Fax: 843-399-9974
Mailing address:
  • Phone: 843-399-9965
  • Fax: 843-399-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateSC

VIII. Authorized Official

Name: DR. KENNETH RAY WARRICK
Title or Position: OWNER
Credential: M.D.
Phone: 843-399-9965