Provider Demographics
NPI:1912400300
Name:CAROLINA CARDIOLOGY AND VASCULAR ASSOCIATES LLC
Entity Type:Organization
Organization Name:CAROLINA CARDIOLOGY AND VASCULAR ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOUKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-888-2282
Mailing Address - Street 1:1 WELLNESS BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2872
Mailing Address - Country:US
Mailing Address - Phone:180-388-8228
Mailing Address - Fax:803-888-2299
Practice Address - Street 1:1 WELLNESS BLVD STE 106
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2872
Practice Address - Country:US
Practice Address - Phone:803-888-2282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17456207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1427057009OtherDR. DANIEL BOUKNIGHT INDIVIDUAL NPI
SC174563Medicaid
SC17456OtherSC LICENSE