Provider Demographics
NPI:1194363580
Name:EPICENTRE, LLC
Entity Type:Organization
Organization Name:EPICENTRE, LLC
Other - Org Name:THE EPICENTRE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENOSHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-804-6010
Mailing Address - Street 1:2048 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-804-6010
Mailing Address - Fax:843-804-6011
Practice Address - Street 1:2048 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-804-6010
Practice Address - Fax:843-804-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9552Medicaid
SCPG0022Medicaid