Healthcare Provider Details

I. General information

NPI: 1982152906
Provider Name (Legal Business Name): COMPLETE CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 HIGHWAY 17 S SUITE 1200
SURFSIDE BEACH SC
29575-6040
US

IV. Provider business mailing address

1413 HIGHWAY 17 S SUITE 1200
SURFSIDE BEACH SC
29575-6040
US

V. Phone/Fax

Practice location:
  • Phone: 843-631-4656
  • Fax:
Mailing address:
  • Phone: 843-631-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. TINA J LESTER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 804-939-7037