Provider Demographics
NPI:1497322325
Name:NORTHEAST ELITE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:NORTHEAST ELITE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUMPH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:803-836-8679
Mailing Address - Street 1:136-4 FORUM DR
Mailing Address - Street 2:1018
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:803-836-8679
Mailing Address - Fax:803-800-2007
Practice Address - Street 1:136-4 FORUM DR
Practice Address - Street 2:1018
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-836-8679
Practice Address - Fax:803-800-2007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care