Healthcare Provider Details

I. General information

NPI: 1427418318
Provider Name (Legal Business Name): PROVIDENCE HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 FOREST DR
COLUMBIA SC
29204-2026
US

IV. Provider business mailing address

2435 FOREST DR
COLUMBIA SC
29204-2026
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-5640
  • Fax: 803-256-5913
Mailing address:
  • Phone: 803-256-5640
  • Fax: 803-256-5913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY SERAPHINE
Title or Position: PRESIDENT
Credential:
Phone: 615-920-7000