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General NPI Number Information
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NPI Number | 1063680197
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Entity Type | Organization
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Legal Business Name | CAROLINA GASTROENTEROLOGY & NUTRITION CLINICS, LLC
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Dates
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Enumeration Date | 02/12/2008
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Last Update Date | 08/21/2018
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Provider Practice Location Address
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Address Line | 102 WAPPOO CREEK DR STE 10C
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City | CHARLESTON
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State | SC
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Zip | 29412
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Country | US
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Telephone | 843-762-9321
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Fax | 843-377-1580
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Provider Business Mailing Address
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Address Line | 102 WAPPOO CREEK DR STE 10C
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City | CHARLESTON
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State | SC
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Zip | 29412-2144
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Country | US
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Telephone | 843-762-9321
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Fax | 843-377-1580
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CHARLES ALLEN BICKERSTAFF JR.
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Credential | M.D.
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Telephone | 843-762-9321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 8659
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License Number State | SC
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