Provider Demographics
NPI:1447420815
Name:MINUTECLINIC DIAGNOSTIC SOUTH CAROLINA LLC
Entity Type:Organization
Organization Name:MINUTECLINIC DIAGNOSTIC SOUTH CAROLINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PINCINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-3813
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:MINUTECLINIC CREDENTIALING
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-0784
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-406-3539
Practice Address - Street 1:698 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-6708
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-406-3539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDO3831OtherMEDICARE RAILROAD
SC9090Medicare PIN