MEDICARE: PIEDMONT CARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1114403342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIEDMONT CARE, INC.

Provider Business Mailing Address
First Line	:	101 N PINE ST STE 200
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29302-1604
Country	:	US
Telephone Number	:	864-582-7773
Fax Number	:	864-582-8637

Provider Business Practice Location Address
First Line	:	101 N PINE ST STE 200
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29302-1604
Country	:	US
Telephone Number	:	864-582-7773
Fax Number	:	864-582-8637

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TRACEY JACKSON
Credential	:
Telephone Number	:	864-582-7773

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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