Provider Demographics
NPI:1801059928
Name:PALMETTO HEALTH &WELLNESS/OASIS SKINCARE
Entity type:Organization
Organization Name:PALMETTO HEALTH &WELLNESS/OASIS SKINCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR (OWNER)
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-535-3961
Mailing Address - Street 1:1101 COOK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8204
Mailing Address - Country:US
Mailing Address - Phone:803-535-3961
Mailing Address - Fax:803-535-3962
Practice Address - Street 1:1101 COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8204
Practice Address - Country:US
Practice Address - Phone:803-535-3961
Practice Address - Fax:803-535-3962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OASIS SKINCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19256261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE85458Medicare UPIN