Healthcare Provider Details

I. General information

NPI: 1700523347
Provider Name (Legal Business Name): SOUTHERN PALMETTO PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 CHESTER AVE STE C
GREAT FALLS SC
29055-1207
US

IV. Provider business mailing address

503 CHESTER AVE STE C
GREAT FALLS SC
29055-1207
US

V. Phone/Fax

Practice location:
  • Phone: 803-482-5904
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA STARNES
Title or Position: OWNER
Credential: FNP
Phone: 803-287-7019