1407991128 NPI number — PAMELA R DEMENT PT

Table of content: PAMELA R DEMENT PT (NPI 1407991128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407991128 NPI number — PAMELA R DEMENT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMENT
Provider First Name:
PAMELA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UNGERMAN
Provider Other First Name:
PAMELA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407991128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2720 SUNSET BLVD
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29169-4810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-936-7679
Provider Business Mailing Address Fax Number:
803-791-2122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 SUNSET BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-4810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-791-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3613 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3613 . This is a "PT LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".