Healthcare Provider Details

I. General information

NPI: 1932989464
Provider Name (Legal Business Name): MARGO CALDWELL BRANDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GREENE ST
COLUMBIA SC
29208-4001
US

IV. Provider business mailing address

1601 GREENE ST
COLUMBIA SC
29208-4001
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-7412
  • Fax:
Mailing address:
  • Phone: 803-777-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5019748
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: