Provider Demographics
NPI: | 1376055038 |
---|---|
Name: | PALMETTO EXPRESS CLINIC, LLC |
Entity Type: | Organization |
Organization Name: | PALMETTO EXPRESS CLINIC, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BRANDY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VAN HEYDE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | NP |
Authorized Official - Phone: | 843-750-0324 |
Mailing Address - Street 1: | 11871 PLAZA DRIVE |
Mailing Address - Street 2: | UNIT 3 |
Mailing Address - City: | MURRELLS INLET |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29576 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-750-0324 |
Mailing Address - Fax: | 855-798-0107 |
Practice Address - Street 1: | 11871 PLAZA DRIVE |
Practice Address - Street 2: | UNIT 3 |
Practice Address - City: | MURRELLS INLET |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29576 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-750-0324 |
Practice Address - Fax: | 855-798-0107 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-11-02 |
Last Update Date: | 2019-05-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Single Specialty |