Provider Demographics
NPI:1629457650
Name:PALMETTO PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:PALMETTO PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-779-3263
Mailing Address - Street 1:2611 FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2371
Mailing Address - Country:US
Mailing Address - Phone:803-779-3263
Mailing Address - Fax:803-779-3207
Practice Address - Street 1:2611 FOREST DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2371
Practice Address - Country:US
Practice Address - Phone:803-779-3263
Practice Address - Fax:803-779-3207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13894332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB91429Medicare UPIN