=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114957891
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLETON AMBULATORY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 MEDICAL PARK DR
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-5743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-782-2700
-----------------------------------------------------
Fax | 843-782-2701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 MEDICAL PARK DR
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-5743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-782-2700
-----------------------------------------------------
Fax | 843-782-2701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DERON SMITH III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-782-2610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | ASF-035
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------