Healthcare Provider Details

I. General information

NPI: 1073218418
Provider Name (Legal Business Name): TINA L. PERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 GERVAIS ST STE 204
COLUMBIA SC
29201-3415
US

IV. Provider business mailing address

97 SUMMIT RIDGE CIR
COLUMBIA SC
29229-7148
US

V. Phone/Fax

Practice location:
  • Phone: 803-401-5137
  • Fax:
Mailing address:
  • Phone: 803-556-1992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberIHCP-1870
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberIHCP-1870
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberIHCP-1870
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License NumberIHCP-1870
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License NumberIHCP-1870
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberIHCP-1870
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License NumberIHCP-1870
License Number StateSC
# 8
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberIHCP-1870
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: