Healthcare Provider Details

I. General information

NPI: 1184829392
Provider Name (Legal Business Name): PALMETTO AIDS LIFE SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2638 TWO NOTCH RD SUITE 108
COLUMBIA SC
29204-1454
US

IV. Provider business mailing address

2638 TWO NOTCH RD SUITE 108
COLUMBIA SC
29204-1454
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-7257
  • Fax: 803-779-5285
Mailing address:
  • Phone: 803-779-7257
  • Fax: 803-779-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: MS. CARMEN HAMPTON JULIOUS
Title or Position: EXECUTIVE DIRECTOR
Credential: LISW-CP&AP
Phone: 803-779-7257