Provider Demographics
NPI:1124664743
Name:R MATHIS 002 LLC
Entity type:Organization
Organization Name:R MATHIS 002 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-415-0931
Mailing Address - Street 1:230 N GROVE MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-4222
Mailing Address - Country:US
Mailing Address - Phone:864-310-6888
Mailing Address - Fax:
Practice Address - Street 1:2830 REIDVILLE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5640
Practice Address - Country:US
Practice Address - Phone:864-574-0762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty