Provider Demographics
NPI:1790319408
Name:CONSULTORIO MEDICO LATINO
Entity Type:Organization
Organization Name:CONSULTORIO MEDICO LATINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-735-1887
Mailing Address - Street 1:2810 ASHLEY PHOSPHATE RD STE B4
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-6406
Mailing Address - Country:US
Mailing Address - Phone:843-553-7744
Mailing Address - Fax:843-553-7734
Practice Address - Street 1:2810 ASHLEY PHOSPHATE RD STE B4
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6406
Practice Address - Country:US
Practice Address - Phone:843-553-7744
Practice Address - Fax:843-553-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty