Healthcare Provider Details

I. General information

NPI: 1730860552
Provider Name (Legal Business Name): PALMETTO SPECIALTY LONG TERM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 GADSDEN ST
COLUMBIA SC
29201-2038
US

IV. Provider business mailing address

2315 GADSDEN ST
COLUMBIA SC
29201-2038
US

V. Phone/Fax

Practice location:
  • Phone: 803-260-1019
  • Fax:
Mailing address:
  • Phone: 803-260-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN JOHN MCDERMOTT
Title or Position: OWNER/CEO
Credential:
Phone: 843-513-4120