Healthcare Provider Details

I. General information

NPI: 1134943459
Provider Name (Legal Business Name): NOVANT HEALTH SOUTHEASTERN SPINE INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 07/01/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 HOSPITAL DR
MT PLEASANT SC
29464-3698
US

IV. Provider business mailing address

2085 FRONTIS PLAZA BLVD
WINSTON SALEM NC
27103-5614
US

V. Phone/Fax

Practice location:
  • Phone: 843-849-1551
  • Fax: 843-884-0629
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEEA WALTON
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-6081