Healthcare Provider Details

I. General information

NPI: 1497621759
Provider Name (Legal Business Name): EPICENTRE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2679 LAKE PARK DR
NORTH CHARLESTON SC
29406-9100
US

IV. Provider business mailing address

2048 CHARLIE HALL BLVD
CHARLESTON SC
29414-5830
US

V. Phone/Fax

Practice location:
  • Phone: 843-804-6010
  • Fax:
Mailing address:
  • Phone: 843-804-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENOSHA D GLEATON
Title or Position: OWNER
Credential:
Phone: 843-804-6010