MEDICARE: PRICKLY PALMS 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1720670235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRICKLY PALMS LLC

Provider Business Mailing Address
First Line	:	1350 ASHLEY RIVER RD STE 650
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-5373
Country	:	US
Telephone Number	:	435-691-4545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 ASHLEY RIVER RD STE 650
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-5373
Country	:	US
Telephone Number	:	435-691-4545
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RHETT GILLINS
Credential	:
Telephone Number	:	435-691-4545

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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