=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376416297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIVOT TELEHEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2025
-----------------------------------------------------
Last Update Date | 10/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1722 MAIN ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-356-8458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2011 CEDAR HILL DR
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30296-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANTHONY DENARD BOWDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-710-1516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------