Provider Demographics
NPI:1942733191
Name:LINEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LINEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 WACCAMAW MEDICAL PARK DRIVE
Mailing Address - Street 2:WACCAMAW CENTER FOR MENTAL HEALTH
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526
Mailing Address - Country:US
Mailing Address - Phone:843-347-5060
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DRIVE
Practice Address - Street 2:WACCAMAW CENTER FOR MENTAL HEALTH
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC222104163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse