=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740860238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAGAN MEDICAL CONSULTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2021
-----------------------------------------------------
Last Update Date | 04/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7107 BOWEN CORNER AVE
-----------------------------------------------------
City | HANAHAN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29410-4813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-346-3957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 CLYBURN PL
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29801-4193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-346-3957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING CONSULTANT
-----------------------------------------------------
Name | KHAIRIYA C BRYANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-339-1359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------