Healthcare Provider Details

I. General information

NPI: 1740249622
Provider Name (Legal Business Name): ATIENO ALICE R. RAGWAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 OMNI DR STE B
SENECA SC
29672-9448
US

IV. Provider business mailing address

PO BOX 601082
CHARLOTTE NC
28260-1082
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-4222
  • Fax: 864-888-0023
Mailing address:
  • Phone: 864-885-7989
  • Fax: 864-885-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31617
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number044869
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: