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General NPI Number Information
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NPI Number | 1487361127
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Entity Type | Organization
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Legal Business Name | MIRIAM MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 11/02/2022
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Last Update Date | 11/02/2022
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Provider Practice Location Address
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Address Line | 1926 INDIA HOOK RD
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City | ROCK HILL
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State | SC
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Zip | 29732-1218
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Country | US
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Telephone | 704-904-3367
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Fax |
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Provider Business Mailing Address
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Address Line | 1926 INDIA HOOK RD
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City | ROCK HILL
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State | SC
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Zip | 29732-1218
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Country | US
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Telephone | 704-904-3367
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MARIE FENELON
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Credential | NP
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Telephone | 704-904-3367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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