Provider Demographics
NPI:1073218418
Name:PERRY, TINA L
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 SUMMIT RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7148
Mailing Address - Country:US
Mailing Address - Phone:803-556-1992
Mailing Address - Fax:
Practice Address - Street 1:1717 GERVAIS ST STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3415
Practice Address - Country:US
Practice Address - Phone:803-401-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1870311ZA0620X, 343900000X, 347C00000X, 372500000X, 3747A0650X, 374U00000X, 376J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No372500000XNursing Service Related ProvidersChore Provider
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker