Healthcare Provider Details

I. General information

NPI: 1104013663
Provider Name (Legal Business Name): GREENWOOD GENETICS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 W MONTAGUE AVE STE 104
NORTH CHARLESTON SC
29418-6083
US

IV. Provider business mailing address

101 GREGOR MENDEL CIR
GREENWOOD SC
29646-2316
US

V. Phone/Fax

Practice location:
  • Phone: 843-746-1001
  • Fax: 843-846-1002
Mailing address:
  • Phone: 864-388-1072
  • Fax: 864-388-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL PRIDMORE
Title or Position: COO
Credential:
Phone: 864-941-8100