Provider Demographics
NPI:1609058254
Name:COULTER CLINIC
Entity Type:Organization
Organization Name:COULTER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:CARN
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-534-0438
Mailing Address - Street 1:941 SUMMERS AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4931
Mailing Address - Country:US
Mailing Address - Phone:803-534-0437
Mailing Address - Fax:
Practice Address - Street 1:941 SUMMERS AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4931
Practice Address - Country:US
Practice Address - Phone:803-534-0437
Practice Address - Fax:803-531-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10582261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC105825Medicaid
SCB92610Medicare UPIN
SC105825Medicaid