MEDICARE: SOUTHERN GRACE PAIN & REGENERATIVE MEDICINE

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	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1942836754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN GRACE PAIN & REGENERATIVE MEDICINE

Provider Business Mailing Address
First Line	:	2256 BECKENHAM DR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29466-9009
Country	:	US
Telephone Number	:	843-754-4231
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 PARK AVENUE BLVD., SUITE 105
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466
Country	:	US
Telephone Number	:	843-754-4231
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER/OWNER
Name	:	DR. WILLIAM BLANE BLANE RICHARDSON
Credential	:	MD
Telephone Number	:	843-754-4231

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	03/13/2020

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