Provider Demographics
NPI:1194829218
Name:BURNT CHURCH PRIMARY AND URGENT CARE, LLC
Entity Type:Organization
Organization Name:BURNT CHURCH PRIMARY AND URGENT CARE, LLC
Other - Org Name:SOUTH CAROLINA HEALTH SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:25 HOSPITAL CENTER BLVD
Mailing Address - Street 2:ATTN ADMINISTRATION- KIM HOLSTEIN
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2738
Mailing Address - Country:US
Mailing Address - Phone:843-757-9229
Mailing Address - Fax:
Practice Address - Street 1:1 BURNT CHURCH RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6405
Practice Address - Country:US
Practice Address - Phone:843-757-9229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherTAX ID