Provider Demographics
NPI:1942836754
Name:SOUTHERN GRACE PAIN & REGENERATIVE MEDICINE
Entity Type:Organization
Organization Name:SOUTHERN GRACE PAIN & REGENERATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM BLANE
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-754-4231
Mailing Address - Street 1:2256 BECKENHAM DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9009
Mailing Address - Country:US
Mailing Address - Phone:843-754-4231
Mailing Address - Fax:
Practice Address - Street 1:3520 PARK AVENUE BLVD., SUITE 105
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466
Practice Address - Country:US
Practice Address - Phone:843-754-4231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain