=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285903310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY PASTOR CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7356 GARNERS FERRY RD SUITE 125
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29209-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-834-5572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7356 GARNERS FERRY RD SUITE 125
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29209-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-834-5572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SAMMY WADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-834-5572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343800000X
-----------------------------------------------------
Taxonomy Name | Secured Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------