1427432046 NPI number — PALMETTO CENTER FOR CHANGE, LLC

Table of content: (NPI 1427432046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427432046 NPI number — PALMETTO CENTER FOR CHANGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALMETTO CENTER FOR CHANGE, LLC
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:
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:
1427432046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 483
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29054-0483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-851-0902
Provider Business Mailing Address Fax Number:
803-851-7192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 SUNSET BLVD STE C
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:
29169-5955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-851-0902
Provider Business Practice Location Address Fax Number:
803-851-7192
Provider Enumeration Date:
07/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
E. O.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-851-0902

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6960 , 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: 616366600 . This is a "DOL" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SW1077 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP7051 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 612752000 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: Q371020281 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: QMP000002409221 . This is a "MOLINA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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