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General NPI Number Information
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NPI Number | 1225456247
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Entity Type | Organization
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Legal Business Name | ANCIENT MARINER, LLC
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Dates
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Enumeration Date | 04/07/2014
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Last Update Date | 10/27/2015
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Provider Practice Location Address
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Address Line | 1118 GREENLAWN DR
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City | COLUMBIA
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State | SC
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Zip | 29209-2606
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Country | US
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Telephone | 803-807-2140
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Fax |
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Provider Business Mailing Address
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Address Line | 7457 PATTERSON RD STE 107
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City | COLUMBIA
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State | SC
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Zip | 29209-0710
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Country | US
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Telephone | 803-807-2140
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Fax | 803-807-2141
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | TONIA PATTERSON
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Credential |
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Telephone | 803-600-7211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2905
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License Number State | SC
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