Healthcare Provider Details

I. General information

NPI: 1932903010
Provider Name (Legal Business Name): TIFFANY GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N MAIN ST
SUMTER SC
29150-4258
US

IV. Provider business mailing address

319 N MAIN ST
SUMTER SC
29150-4258
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL95086
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: