Healthcare Provider Details

I. General information

NPI: 1730040189
Provider Name (Legal Business Name): THE PALACE CORPORATE OFFICE & WAREHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 LADY ST
COLUMBIA SC
29201-3218
US

IV. Provider business mailing address

1122 LADY ST
COLUMBIA SC
29201-3218
US

V. Phone/Fax

Practice location:
  • Phone: 803-995-2153
  • Fax: 803-995-2153
Mailing address:
  • Phone: 803-995-2153
  • Fax: 803-995-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: TARA KAY MARTIN
Title or Position: CEO, CORPORATE EXECUTIVE OFFICER
Credential: CPA, EA, PTIN
Phone: 803-995-2153