Provider Demographics
NPI:1144299470
Name:HOPE CLINIC LLC
Entity type:Organization
Organization Name:HOPE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-408-4171
Mailing Address - Street 1:110 EXECUTIVE PKWY
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3930
Mailing Address - Country:US
Mailing Address - Phone:843-408-4171
Mailing Address - Fax:888-318-5567
Practice Address - Street 1:110 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3930
Practice Address - Country:US
Practice Address - Phone:843-899-9099
Practice Address - Fax:888-318-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20234207R00000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC202346Medicaid
4225947OtherNCPDP PROVIDER IDENTIFICATION NUMBER
SCGP3438Medicaid