Provider Demographics
NPI:1114957891
Name:COLLETON AMBULATORY CARE, LLC
Entity Type:Organization
Organization Name:COLLETON AMBULATORY CARE, LLC
Other - Org Name:COLLETON AMBULATORY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-782-2610
Mailing Address - Street 1:304 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5743
Mailing Address - Country:US
Mailing Address - Phone:843-782-2700
Mailing Address - Fax:843-782-2701
Practice Address - Street 1:304 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5743
Practice Address - Country:US
Practice Address - Phone:843-782-2700
Practice Address - Fax:843-782-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCASF-035261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCASC014Medicaid
SCASC014Medicaid
SC=========OtherBLUE CROSS / BLUE SHIELD