Healthcare Provider Details

I. General information

NPI: 1720154107
Provider Name (Legal Business Name): LOW COUNTRY OUTREACH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S WHEELER AVE
PROSPERITY SC
29127-9347
US

IV. Provider business mailing address

7001 SAINT ANDREWS RD STE 319
COLUMBIA SC
29212-1137
US

V. Phone/Fax

Practice location:
  • Phone: 803-546-0526
  • Fax:
Mailing address:
  • Phone: 803-546-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: DANITA ROSSER JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 803-546-0526