Healthcare Provider Details

I. General information

NPI: 1295655587
Provider Name (Legal Business Name): GEODE HEALTH OF SOUTH CAROLINA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CLEBOURNE ST STE 310
FORT MILL SC
29715-1758
US

IV. Provider business mailing address

1211 W 22ND ST STE 406
OAK BROOK IL
60523-2169
US

V. Phone/Fax

Practice location:
  • Phone: 888-902-1704
  • Fax:
Mailing address:
  • Phone: 888-902-1704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BRANDY MARRINER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-912-4241