Healthcare Provider Details

I. General information

NPI: 1306032214
Provider Name (Legal Business Name): ADJUTANT GENERAL OF SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 LEESBURG RD.
EASTOVER SC
29044-9184
US

IV. Provider business mailing address

1 NATIONAL GUARD RD
COLUMBIA SC
29201-4752
US

V. Phone/Fax

Practice location:
  • Phone: 803-832-4876
  • Fax: 803-832-4880
Mailing address:
  • Phone: 803-331-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberPR38913
License Number StateSC

VIII. Authorized Official

Name: JACKIE FOGLE
Title or Position: DIRECTOR
Credential:
Phone: 803-331-6675