Provider Demographics
NPI:1396161808
Name:SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC
Entity type:Organization
Organization Name:SOUTHEAST NEUROPATHY & TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-240-5399
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-0026
Mailing Address - Country:US
Mailing Address - Phone:803-240-5399
Mailing Address - Fax:803-791-1634
Practice Address - Street 1:1494 LAKE MURRAY BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-8697
Practice Address - Country:US
Practice Address - Phone:803-240-5399
Practice Address - Fax:803-791-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain