Provider Demographics
NPI:1184829392
Name:PALMETTO AIDS LIFE SUPPORT SERVICES
Entity Type:Organization
Organization Name:PALMETTO AIDS LIFE SUPPORT SERVICES
Other - Org Name:PALSS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:HAMPTON
Authorized Official - Last Name:JULIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP&AP
Authorized Official - Phone:803-779-7257
Mailing Address - Street 1:2638 TWO NOTCH RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1454
Mailing Address - Country:US
Mailing Address - Phone:803-779-7257
Mailing Address - Fax:803-779-5285
Practice Address - Street 1:2638 TWO NOTCH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1454
Practice Address - Country:US
Practice Address - Phone:803-779-7257
Practice Address - Fax:803-779-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0210Medicaid