NPI |
1851177554 |
The first name of the provider, if the provider
is an individual. |
Entity Type Code |
1 |
The middle name of the provider, if the provider
is an individual. |
Provider Last Name Legal Name |
BLANTON |
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider First Name |
KAYLA |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
MOODY |
The city name in the location address of the provider being identified. |
Provider First Line Business Practice Location Address |
164 WACCAMAW MEDICAL PARK |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address City Name |
CONWAY |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
SC |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
295268903 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address Telephone Number |
8432344888 |
The date that a record was last updated or changed. |
Provider Enumeration Date |
9/7/2023 |
The code designating the provider’s gender if the provider is a person. |
Last Update Date |
9/7/2023 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Gender Code |
F |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Healthcare Provider Taxonomy Code 1 |
163WC0400X |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider License Number 1 |
237170 |
|
Provider License Number State Code 1 |
SC |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
NPI Certification Date |
9/7/2023 |
|