Provider Demographics
NPI:1689779688
Name:BOUNTYLAND MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:BOUNTYLAND MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:864-882-6395
Mailing Address - Street 1:1741 BLUE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-6613
Mailing Address - Country:US
Mailing Address - Phone:864-882-6395
Mailing Address - Fax:864-882-9248
Practice Address - Street 1:1741 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-6613
Practice Address - Country:US
Practice Address - Phone:864-882-6395
Practice Address - Fax:864-882-9248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC719111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6918Medicare ID - Type Unspecified
SCU30879Medicare UPIN