Healthcare Provider Details

I. General information

NPI: 1366853756
Provider Name (Legal Business Name): TAMARA PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 CLIVE ST
COLUMBIA SC
29204-3021
US

IV. Provider business mailing address

4840 FOREST DR SUITE 6-B, #259
COLUMBIA SC
29206-4810
US

V. Phone/Fax

Practice location:
  • Phone: 803-530-5314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: