Healthcare Provider Details

I. General information

NPI: 1730752015
Provider Name (Legal Business Name): ANGELIC PRIMARY MEDICINE OF SC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4728 JENN DR STE 102
MYRTLE BEACH SC
29577-5714
US

IV. Provider business mailing address

8025 BLACK HORSE PIKE STE 501
PLEASANTVILLE NJ
08232-2967
US

V. Phone/Fax

Practice location:
  • Phone: 609-464-1135
  • Fax: 609-822-7980
Mailing address:
  • Phone: 609-822-7979
  • Fax: 609-822-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier24726
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerLICENSE

VIII. Authorized Official

Name: JANET GIBSON
Title or Position: OWNER
Credential: APN
Phone: 609-464-1135