Provider Demographics
NPI:1710109822
Name:THE CYPRESS CLUB, INC.
Entity Type:Organization
Organization Name:THE CYPRESS CLUB, INC.
Other - Org Name:THE CYPRESS CLUB CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PUNTERERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-689-7007
Mailing Address - Street 1:20 LADYSLIPPER LN
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1372
Mailing Address - Country:US
Mailing Address - Phone:843-682-7116
Mailing Address - Fax:843-689-7084
Practice Address - Street 1:20 LADYSLIPPER LN
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-682-7116
Practice Address - Fax:843-689-7084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCHHA-146OtherSTATE LICENSE NUMBER
SCHHA-146OtherSTATE LICENSE NUMBER