Healthcare Provider Details

I. General information

NPI: 1497295174
Provider Name (Legal Business Name): THE PEDIATRIC CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6614 AUGUSTA HWY
LEESVILLE SC
29070-9213
US

IV. Provider business mailing address

6614 AUGUSTA HWY
LEESVILLE SC
29070-9213
US

V. Phone/Fax

Practice location:
  • Phone: 803-604-8400
  • Fax: 803-604-8404
Mailing address:
  • Phone: 803-604-8400
  • Fax: 803-604-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21070
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRANDY SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 803-604-8400