Provider Demographics
NPI:1093394389
Name:DISTINGUISHED CROWNS LLC
Entity Type:Organization
Organization Name:DISTINGUISHED CROWNS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANZIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMONS WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-624-0373
Mailing Address - Street 1:PO BOX 12176
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29504-2176
Mailing Address - Country:US
Mailing Address - Phone:843-624-0373
Mailing Address - Fax:
Practice Address - Street 1:4001 E PALMETTO ST STE 1305
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-4213
Practice Address - Country:US
Practice Address - Phone:843-624-0373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment