Provider Demographics
NPI:1396386942
Name:THE BHANG GROUP
Entity Type:Organization
Organization Name:THE BHANG GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PRUNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:803-724-1250
Mailing Address - Street 1:1320 MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3266
Mailing Address - Country:US
Mailing Address - Phone:803-724-1250
Mailing Address - Fax:803-724-1200
Practice Address - Street 1:1320 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3266
Practice Address - Country:US
Practice Address - Phone:803-724-1250
Practice Address - Fax:803-724-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8820353071Medicaid