Provider Demographics
NPI:1417320375
Name:ELITE ORTHOPAEDICS OF SOUTH CAROLINA, LLC
Entity Type:Organization
Organization Name:ELITE ORTHOPAEDICS OF SOUTH CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENEANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-546-9591
Mailing Address - Street 1:235 SINGLETON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9136
Mailing Address - Country:US
Mailing Address - Phone:843-347-4357
Mailing Address - Fax:
Practice Address - Street 1:235 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9136
Practice Address - Country:US
Practice Address - Phone:843-347-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL37747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty