Provider Demographics
NPI:1396290995
Name:MEGGETT TIVA LLC
Entity type:Organization
Organization Name:MEGGETT TIVA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RAEDORD
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:843-860-0324
Mailing Address - Street 1:PO BOX 4860
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-2698
Mailing Address - Country:US
Mailing Address - Phone:843-651-2624
Mailing Address - Fax:843-491-4023
Practice Address - Street 1:4731 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5090
Practice Address - Country:US
Practice Address - Phone:843-839-7246
Practice Address - Fax:843-491-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty