Provider Demographics
NPI:1407475676
Name:AMETHYST HEALTH, LLC
Entity Type:Organization
Organization Name:AMETHYST HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WACHOVIA
Authorized Official - Middle Name:CHANTA'
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:717-880-3740
Mailing Address - Street 1:1175 GREY PINE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7320
Mailing Address - Country:US
Mailing Address - Phone:717-880-3740
Mailing Address - Fax:
Practice Address - Street 1:1175 GREY PINE DR
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7320
Practice Address - Country:US
Practice Address - Phone:717-880-3740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty