Healthcare Provider Details

I. General information

NPI: 1114497757
Provider Name (Legal Business Name): PALMETTO PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FINANCIAL BLVD
ANDERSON SC
29621-1770
US

IV. Provider business mailing address

10 FINANCIAL BLVD
ANDERSON SC
29621-1770
US

V. Phone/Fax

Practice location:
  • Phone: 864-437-8930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS JAMES WINKLER
Title or Position: OWNER
Credential:
Phone: 864-225-8431