Healthcare Provider Details

I. General information

NPI: 1003732025
Provider Name (Legal Business Name): DECIPHER MEDICAL AT PALMETTO BLUFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BUCKHEAD BAY RD UNIT 1501
BLUFFTON SC
29910-8071
US

IV. Provider business mailing address

15 BUCKHEAD BAY RD UNIT 1501
BLUFFTON SC
29910-8071
US

V. Phone/Fax

Practice location:
  • Phone: 210-861-9819
  • Fax:
Mailing address:
  • Phone: 210-861-9819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SANTOS JOHN DOMINGUEZ II
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 210-861-9819