Healthcare Provider Details

I. General information

NPI: 1760337232
Provider Name (Legal Business Name): LEROY A GRIFFIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 VAUGHT PL UNIT 101
MYRTLE BEACH SC
29588-3716
US

IV. Provider business mailing address

131 VAUGHT PL UNIT 101
MYRTLE BEACH SC
29588-3716
US

V. Phone/Fax

Practice location:
  • Phone: 843-457-0529
  • Fax:
Mailing address:
  • Phone: 843-457-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number102641107
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: