Healthcare Provider Details

I. General information

NPI: 1801241971
Provider Name (Legal Business Name): PALMETTO SENIOR CARE SHANDON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SHIRLEY ST STE 1
COLUMBIA SC
29205-1370
US

IV. Provider business mailing address

1100 SHIRLEY ST STE 1
COLUMBIA SC
29205-1370
US

V. Phone/Fax

Practice location:
  • Phone: 803-252-1979
  • Fax:
Mailing address:
  • Phone: 803-252-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number19802
License Number StateSC

VIII. Authorized Official

Name: DR. JOHN EGBERT
Title or Position: PACE EXECUTIVE MD
Credential: MD, PHD
Phone: 803-252-1979