Healthcare Provider Details

I. General information

NPI: 1326305210
Provider Name (Legal Business Name): CAROLINA PEDIATRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SCHOOL ST 3
RIDGEVILLE SC
29472-8040
US

IV. Provider business mailing address

105 SCHOOL HOUSE ST 3
RIDGEVILLE SC
29472
US

V. Phone/Fax

Practice location:
  • Phone: 843-364-1363
  • Fax:
Mailing address:
  • Phone: 843-364-1363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. ALETHA MOSLEY
Title or Position: OP DIRECTOR
Credential:
Phone: 843-364-1363