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General NPI Number Information
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NPI Number | 1235245812
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Entity Type | Organization
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Legal Business Name | COLLETON OTOLARYNGOLOGY, HEAD & NECK SURGERY, LLC
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 02/04/2008
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Provider Practice Location Address
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Address Line | 302 MEDICAL PARK DR SUITE 211
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City | WALTERBORO
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State | SC
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Zip | 29488-5747
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Country | US
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Telephone | 843-813-6397
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Fax | 866-302-2249
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Provider Business Mailing Address
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Address Line | 302 MEDICAL PARK DR SUITE 211
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City | WALTERBORO
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State | SC
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Zip | 29488-5747
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Country | US
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Telephone | 843-813-6397
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Fax | 866-302-2249
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Authorized Official
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Title or Position | VICE-PRESIDENT OF OPERATIONS
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Name | MARK PICKETT
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Credential |
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Telephone | 678-762-5037
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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 |
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License Number State |
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