Healthcare Provider Details

I. General information

NPI: 1407397227
Provider Name (Legal Business Name): INTERCOSTAL NONSURGICAL DIAGNOSTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 E MAIN ST
WILLIAMSTON SC
29697-1925
US

IV. Provider business mailing address

24 E MAIN ST
WILLIAMSTON SC
29697-1925
US

V. Phone/Fax

Practice location:
  • Phone: 864-847-6020
  • Fax: 864-840-9668
Mailing address:
  • Phone: 864-847-6020
  • Fax: 864-840-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: JACK WISE
Title or Position: OWNER
Credential: DC
Phone: 864-847-6020