Healthcare Provider Details

I. General information

NPI: 1609105444
Provider Name (Legal Business Name): PROFESSIONAL HEALTH SVC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 PENDLETON ST
GREENVILLE SC
29601-2315
US

IV. Provider business mailing address

PO BOX 26062
GREENVILLE SC
29616-1062
US

V. Phone/Fax

Practice location:
  • Phone: 864-242-1747
  • Fax: 864-370-1201
Mailing address:
  • Phone: 864-242-1747
  • Fax: 864-370-1201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR40622
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR40622
License Number StateSC

VIII. Authorized Official

Name: MRS. DORIS D HALEY
Title or Position: PRESIDENT
Credential:
Phone: 864-505-6747