Healthcare Provider Details

I. General information

NPI: 1649702531
Provider Name (Legal Business Name): INVISTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 HIGHWAY 1 S
LUGOFF SC
29078-9174
US

IV. Provider business mailing address

643 HIGHWAY 1 S
LUGOFF SC
29078-9174
US

V. Phone/Fax

Practice location:
  • Phone: 803-425-3363
  • Fax: 803-425-2742
Mailing address:
  • Phone: 803-425-3363
  • Fax: 803-425-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number35976
License Number StateSC

VIII. Authorized Official

Name: MRS. DIANE K FREEMAN
Title or Position: OCCUPATIONAL HEALTH NURSE
Credential: RN
Phone: 803-425-3363