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General NPI Number Information
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NPI Number | 1205723194
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Entity Type | Organization
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Legal Business Name | SELF REGIONAL HEALTHCARE PARTNERS
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Dates
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Enumeration Date | 06/23/2025
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 801 MOBLEY ST
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City | JOHNSTON
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State | SC
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Zip | 29832-1366
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Country | US
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Telephone | 803-275-4653
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Fax |
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Provider Business Mailing Address
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Address Line | 1325 SPRING ST
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City | GREENWOOD
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State | SC
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Zip | 29646-3860
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Country | US
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Telephone | 864-725-4111
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Fax |
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | MATTHEW TOLBERT LOGAN
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Credential | MD
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Telephone | 864-725-4780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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