=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851376180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PILOT CLUB OF COLUMBIA FOUNDATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1746 WESTMINSTER DR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-254-2673
-----------------------------------------------------
Fax | 803-252-3649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50231
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29250-0231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-254-2673
-----------------------------------------------------
Fax | 803-252-3649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC DIRECTOR
-----------------------------------------------------
Name | MR. BUCK BRINSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-765-0574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------