Provider Demographics
NPI:1336133313
Name:AUGUSTA STREET CLINIC LLC
Entity Type:Organization
Organization Name:AUGUSTA STREET CLINIC LLC
Other - Org Name:AUGUSTA STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:JAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-232-0082
Mailing Address - Street 1:1521 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2921
Mailing Address - Country:US
Mailing Address - Phone:864-232-0082
Mailing Address - Fax:864-232-1884
Practice Address - Street 1:1521 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2921
Practice Address - Country:US
Practice Address - Phone:864-232-0082
Practice Address - Fax:864-232-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty