MEDICARE: ETHER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003213174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHER, LLC

Provider Business Mailing Address
First Line	:	1070 WILDWOOD CENTRE DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-8420
Country	:	US
Telephone Number	:	803-788-1100
Fax Number	:	803-788-4522

Provider Business Practice Location Address
First Line	:	1070 WILDWOOD CENTRE DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-8420
Country	:	US
Telephone Number	:	803-788-1100
Fax Number	:	803-788-4522

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. KARLA G SHREVE
Credential	:
Telephone Number	:	803-788-1100

Provider Enumeration Date	:	12/04/2014
Last Update Date	:	04/17/2015

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