Provider Demographics
NPI:1932975711
Name:EBBTIDE COMPREHENSIVE CARE, LLC
Entity Type:Organization
Organization Name:EBBTIDE COMPREHENSIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-491-9955
Mailing Address - Street 1:669 MARINA DR STE A2
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1064 GARDNER RD STE 105-106
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5768
Practice Address - Country:US
Practice Address - Phone:843-491-9955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty