Basic Information
| Provider Information | |||||||||
| NPI: | 1083003941 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MSN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WELLNESS BLVD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 WELLNESS BLVD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039171684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2015 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | NOLES | ||||||||
| AuthorizedOfficialFirstName: | LORETTA | ||||||||
| AuthorizedOfficialMiddleName: | RICARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8039171684 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.