MEDICARE: SOUTHERN PALMETTO PRIMARY CARE LLC

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	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1700523347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PALMETTO PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	503 CHESTER AVE STE C
Second Line	:
City	:	GREAT FALLS
State	:	SC
Zip	:	29055-1207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 CHESTER AVE STE C
Second Line	:
City	:	GREAT FALLS
State	:	SC
Zip	:	29055-1207
Country	:	US
Telephone Number	:	803-482-5904
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTINA STARNES
Credential	:	FNP
Telephone Number	:	803-287-7019

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	05/16/2022

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