Healthcare Provider Details

I. General information

NPI: 1720310055
Provider Name (Legal Business Name): GREEN RIDGE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FORUM DR STE 3-255
COLUMBIA SC
29229-7944
US

IV. Provider business mailing address

100 FORUM DR STE 3-255
COLUMBIA SC
29229-7944
US

V. Phone/Fax

Practice location:
  • Phone: 803-795-5435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number13651
License Number StateSC

VIII. Authorized Official

Name: THOMAS W NORRIS
Title or Position: CEO
Credential:
Phone: 803-795-5435