Healthcare Provider Details

I. General information

NPI: 1003070103
Provider Name (Legal Business Name): MONCKS CORNER PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 EPSON PLANTATION DR SUITE B
MONCKS CORNER SC
29461-3979
US

IV. Provider business mailing address

5000 EPSON PLANTATION DR SUITE B
MONCKS CORNER SC
29461-3979
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-2000
  • Fax: 843-761-2267
Mailing address:
  • Phone: 843-761-2000
  • Fax: 843-761-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH R WEST JR.
Title or Position: OWNER
Credential: M.D.
Phone: 843-761-2000