Healthcare Provider Details

I. General information

NPI: 1932213378
Provider Name (Legal Business Name): FETTER HEALTH CARE NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 EXECUTIVE PKWY
MONCKS CORNER SC
29461-3930
US

IV. Provider business mailing address

51 NASSAU STREET
CHARLESTON SC
29403-5513
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-7744
  • Fax:
Mailing address:
  • Phone: 843-722-4112
  • Fax: 843-577-8960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. REUBEN J PETTIFORD
Title or Position: CEO
Credential:
Phone: 843-722-4112