Healthcare Provider Details

I. General information

NPI: 1467008300
Provider Name (Legal Business Name): PINE HILL INDIAN COMMUNITY DEVELOPMENT INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 09/23/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4631 SAVANNAH HWY
NORTH SC
29112-8180
US

IV. Provider business mailing address

4055 COBURG LN
ORANGEBURG SC
29115-9014
US

V. Phone/Fax

Practice location:
  • Phone: 803-247-2534
  • Fax:
Mailing address:
  • Phone: 803-662-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE MITCHUM
Title or Position: EXECUTIVE DIRECTOR
Credential: MSCJ/LAW, CHW
Phone: 803-662-3777