Healthcare Provider Details

I. General information

NPI: 1982867875
Provider Name (Legal Business Name): LOW COUNTRY PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

793 COOK ROAD
ORANGEBURG SC
29118-9008
US

IV. Provider business mailing address

PO BOX 4860
MURRELLS INLET SC
29576-2698
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-8808
  • Fax: 803-531-3330
Mailing address:
  • Phone: 800-951-7850
  • Fax: 843-357-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number21478
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number21478
License Number StateSC

VIII. Authorized Official

Name: AVINASH GUPTA
Title or Position: OWNER
Credential: M.D.
Phone: 803-531-0029