Provider Demographics
NPI:1457002123
Name:UPSTATE CAROLINA MEDICAL LLC
Entity Type:Organization
Organization Name:UPSTATE CAROLINA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-903-9604
Mailing Address - Street 1:144 THOMAS GREEN BLVD STE 232
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2291
Mailing Address - Country:US
Mailing Address - Phone:864-722-5203
Mailing Address - Fax:864-722-5203
Practice Address - Street 1:144 THOMAS GREEN BLVD STE 232
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2291
Practice Address - Country:US
Practice Address - Phone:864-722-5203
Practice Address - Fax:864-722-5203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-14
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty