Basic Information
| Provider Information | |||||||||
| NPI: | 1295469245 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEDICATED SOUTH CAROLINA HOLDING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEDICATED SENIOR MEDICAL CENTER FOREST TC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1022 CALHOUN ST # 201 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036104199 | ||||||||
| FaxNumber: | 8038307157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2022 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7866187245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEDICATED SOUTH CAROLINA HOLDING, LLC | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.