Healthcare Provider Details

I. General information

NPI: 1205722436
Provider Name (Legal Business Name): ALEXANDER JOHN DESMOND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

137 VIAREGGIO RD
MYRTLE BEACH SC
29579-8430
US

V. Phone/Fax

Practice location:
  • Phone: 843-629-1000
  • Fax:
Mailing address:
  • Phone: 724-581-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31763
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number256733
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: