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General NPI Number Information
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NPI Number | 1316762149
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Entity Type | Organization
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Legal Business Name | MAIN ST MEDICAL - NEW ELLENTON LLC
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Dates
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Enumeration Date | 11/18/2024
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 735 MAIN ST N
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City | NEW ELLENTON
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State | SC
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Zip | 29809-2518
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Country | US
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Telephone | 803-443-0077
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Fax |
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Provider Business Mailing Address
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Address Line | 735 MAIN ST N
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City | NEW ELLENTON
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State | SC
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Zip | 29809-2518
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMY YOUNG HIBBITTS
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Credential |
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Telephone | 803-646-5036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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