Provider Demographics
NPI:1114752409
Name:COLLABORATIVE & INNOVATED CARE
Entity type:Organization
Organization Name:COLLABORATIVE & INNOVATED CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARIDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-222-5395
Mailing Address - Street 1:1016 2ND AVE N STE 203A
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3288
Mailing Address - Country:US
Mailing Address - Phone:843-222-5395
Mailing Address - Fax:866-340-0296
Practice Address - Street 1:1016 2ND AVE N STE 203A
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3288
Practice Address - Country:US
Practice Address - Phone:843-222-5395
Practice Address - Fax:866-340-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty