Healthcare Provider Details

I. General information

NPI: 1285547455
Provider Name (Legal Business Name): PALMETTO PREVENTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 LEINBACH DR STE B1
CHARLESTON SC
29407-7088
US

IV. Provider business mailing address

29 LEINBACH DR STE B1
CHARLESTON SC
29407-7088
US

V. Phone/Fax

Practice location:
  • Phone: 854-238-3438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LEISA STAFFORD
Title or Position: PRACTICE ADMINISTRATOR.
Credential:
Phone: 854-238-3438