Provider Demographics
NPI:1124240999
Name:PALMETTO WELLNESS & INJURY CENTER OF BENNETTSVILLE LLC
Entity type:Organization
Organization Name:PALMETTO WELLNESS & INJURY CENTER OF BENNETTSVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:H
Authorized Official - Last Name:STROUP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-479-6102
Mailing Address - Street 1:102 LINDSAY AVE
Mailing Address - Street 2:PO BOX 432
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-3102
Mailing Address - Country:US
Mailing Address - Phone:843-479-6102
Mailing Address - Fax:843-479-6103
Practice Address - Street 1:102 LINDSAY AVE
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3102
Practice Address - Country:US
Practice Address - Phone:843-479-6102
Practice Address - Fax:843-479-6103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2688111N00000X
SC29388207Q00000X
SC23493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2668Medicaid
SCU84474Medicare UPIN
SCH78300Medicare UPIN
SCU844748094Medicare ID - Type Unspecified