Healthcare Provider Details

I. General information

NPI: 1780073924
Provider Name (Legal Business Name): PALMETTO LONG-TERM CARE COALITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 NUCKOLS RD SUITE 110
GLEN ALLEN VA
23060-9276
US

IV. Provider business mailing address

10900 NUCKOLS RD SUITE 110
GLEN ALLEN VA
23060-9276
US

V. Phone/Fax

Practice location:
  • Phone: 404-822-5378
  • Fax:
Mailing address:
  • Phone: 404-822-5378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENNETH BRATTON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 404-822-5378