Healthcare Provider Details

I. General information

NPI: 1407110802
Provider Name (Legal Business Name): TIFFANY LYNN TRENDA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK SUITE 400 PEDS DEPT -
COLUMBIA SC
29203
US

IV. Provider business mailing address

14 MEDICAL PARK SUITE 400 PEDS DEPT -
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-6979
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL1600
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: