=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497621759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPICENTRE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2025
-----------------------------------------------------
Last Update Date | 10/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2679 LAKE PARK DR
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-804-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2048 CHARLIE HALL BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29414-5830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-804-6010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KENOSHA D GLEATON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-804-6010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------