Healthcare Provider Details

I. General information

NPI: 1164973855
Provider Name (Legal Business Name): LAUREN KUPERUS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 SOCASTEE BLVD
MYRTLE BEACH SC
29588-6111
US

IV. Provider business mailing address

2169 EASTWOODS DR
CONWAY SC
29526-7714
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 843-855-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19898
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: