Provider Demographics
NPI:1174412787
Name:MARQUIS CENTER OF CHARLESTON LLC
Entity type:Organization
Organization Name:MARQUIS CENTER OF CHARLESTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INFRASTRUCTURE
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-402-6622
Mailing Address - Street 1:4447 N CENTRAL EXPY STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4246
Mailing Address - Country:US
Mailing Address - Phone:618-402-6622
Mailing Address - Fax:
Practice Address - Street 1:1470 TOBIAS GADSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4925
Practice Address - Country:US
Practice Address - Phone:618-402-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery