=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255096541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYNORA MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2021
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 SAINT ANDREWS RD STE 216A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29210-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-261-0175
-----------------------------------------------------
Fax | 803-291-5942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 SAINT ANDREWS RD STE 216A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29210-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-261-0175
-----------------------------------------------------
Fax | 803-291-5942
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | PARIS S GARTMON
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 803-386-7559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------