Basic Information
| Provider Information | |||||||||
| NPI: | 1730752015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANGELIC PRIMARY MEDICINE OF SC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8025 BLACK HORSE PIKE STE 501 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082322967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098227979 | ||||||||
| FaxNumber: | 6098227980 | ||||||||
| Practice Location | |||||||||
| Address1: | 923B MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8544449998 | ||||||||
| FaxNumber: | 8433532495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2021 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6094641135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APN | ||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 24726 | 01 | SC | LICENSE | OTHER |