=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265930697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO OFS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2018
-----------------------------------------------------
Last Update Date | 12/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2849 N PLEASANTBURG DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29609-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-714-1800
-----------------------------------------------------
Fax | 864-714-1805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3021 AMBERBROOK LN
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29414-8125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-420-2738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRETT M. SHIGLEY
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 864-714-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 8374
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------