Healthcare Provider Details

I. General information

NPI: 1831498559
Provider Name (Legal Business Name): JAY GODINES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W WESMARK BLVD
SUMTER SC
29150-1983
US

IV. Provider business mailing address

PO BOX 7332
COLUMBIA SC
29202-7332
US

V. Phone/Fax

Practice location:
  • Phone: 803-905-5590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMIRO JAY GODINES
Title or Position: OWNER/MD
Credential: MD
Phone: 803-765-1838