Healthcare Provider Details

I. General information

NPI: 1902422850
Provider Name (Legal Business Name): PRECIOUS JEWELS MEDICAL & HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WESTERN LN STE B
IRMO SC
29063-7953
US

IV. Provider business mailing address

401 WESTERN LN STE B
IRMO SC
29063-7953
US

V. Phone/Fax

Practice location:
  • Phone: 803-830-9095
  • Fax:
Mailing address:
  • Phone: 803-834-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NIKITA SHANEKA PETE
Title or Position: MEDICAL OFFICER
Credential:
Phone: 803-830-7075