| NPI | 1790592491 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TAMMY PORTER Provider Enrollment COO Rdinator 843-663-8000 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QM1300X Clinic/Center Multi-Specialty |
| Additional Taxonomies | 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2024-12-16 |
| Last Update Date | 2024-12-16 |