1073696662 NPI number — STATE OF SOUTH CAROLINA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073696662 NPI number — STATE OF SOUTH CAROLINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF SOUTH CAROLINA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073696662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 OTARRE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAYCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29033-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-898-1553
Provider Business Mailing Address Fax Number:
803-898-2262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1016 OLD LATTA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29536-7614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-774-5611
Provider Business Practice Location Address Fax Number:
843-841-0835
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERKINS
Authorized Official First Name:
ZANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR PATIENT BILLING
Authorized Official Telephone Number:
803-898-1553

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 601240 . This is a "SELECT HEALTH PROVIDER #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 000000155825 . This is a "UNISON HEALTH PLAN OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DHEC17 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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