=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508670837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND STRAND MOBILE WOUND CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2025
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1297 PROFESSIONAL DR STE 201
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29577-5713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-999-6863
-----------------------------------------------------
Fax | 855-834-3003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 580 STARLIT WAY
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-4322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-999-6863
-----------------------------------------------------
Fax | 855-834-3003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JEFFREY HATHWAY
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 617-959-4427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------