Healthcare Provider Details

I. General information

NPI: 1255322806
Provider Name (Legal Business Name): PALMETTO RETINA CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SUNSET COURT
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

124 SUNSET COURT
WEST COLUMBIA SC
29169
US

V. Phone/Fax

Practice location:
  • Phone: 803-931-0077
  • Fax: 803-931-0076
Mailing address:
  • Phone: 803-931-0077
  • Fax: 803-931-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A WELLS III
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 803-931-0077