Provider Demographics
NPI:1639422892
Name:THE CLINIC
Entity Type:Organization
Organization Name:THE CLINIC
Other - Org Name:LA CLINICA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GIUSEPPE
Authorized Official - Middle Name:BALIN
Authorized Official - Last Name:DEABATE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:843-338-1337
Mailing Address - Street 1:157 WILLIAM HILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-5218
Mailing Address - Country:US
Mailing Address - Phone:843-681-8260
Mailing Address - Fax:
Practice Address - Street 1:157 WILLIAM HILTON PKWY
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-5218
Practice Address - Country:US
Practice Address - Phone:843-681-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA1897364SA2200X
SCP1897364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA10337919OtherMEDICARE ID-TYPE UNSPECIFIED
SCNP0909Medicaid
SCQ49378Medicare UPIN