=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023105277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLERGY AND ASTHMA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2006
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7045A SAINT ANDREWS RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29212-1177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-407-0385
-----------------------------------------------------
Fax | 803-407-0389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7045 SAINT ANDREWS RD # A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29212-1177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-407-0385
-----------------------------------------------------
Fax | 803-407-0389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LAURA W DOUGHERTY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 803-407-0385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 28749
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------