NPIMap

Organization Active NPI

Table Rock Integrated Health and Wellness Practice, LLC.

  • Psychiatry Physician
  • Travelers Rest, SC
National Provider Identifier
1104145184
Registry record updated Mar 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
30719 Issued in SC
Legal business name
TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.
Practice address
5 Center St
Travelers Rest, SC 29690-1826
Phone
(864) 908-6372
Fax
(864) 898-3703
NPI assigned
May 31, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 16, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Gergana Damianova Dimitrova, M.D.NPI 1326129388
Title
Partner
Phone
(864) 908-6372

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X 1223 SC
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 5825 SC
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X 30719 SC Primary
Geriatric Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0805X 30719 SC

Addresses

Primary practice location

5 Center St
Travelers Rest, SC 29690-1826

Mailing address

5 Center St
Travelers Rest, SC 29690-1826
Phone (864) 908-6372

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101013000875 SC Part B Supplier - Clinic/Group Practice 0648462333 Receives reassigned benefits from 5 practitioners
Practice locations: Travelers Rest, SC

National Provider Directory

National Provider Directory

Locations

5 Center St
Travelers Rst, SC 29690
Phone (864) 908-6372

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1275264000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584316800000",
    "number": "1104145184",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5 CENTER ST",
            "city": "TRAVELERS REST",
            "state": "SC",
            "postal_code": "296901826",
            "telephone_number": "864-908-6372",
            "fax_number": "864-898-3703"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5 CENTER ST",
            "city": "TRAVELERS REST",
            "state": "SC",
            "postal_code": "296901826",
            "telephone_number": "864-908-6372",
            "fax_number": "864-898-3703"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TABLE ROCK INTEGRATED HEALTH AND WELLNESS PRACTICE, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-31",
        "last_updated": "2020-03-16",
        "certification_date": "2020-03-16",
        "status": "A",
        "authorized_official_last_name": "DIMITROVA",
        "authorized_official_first_name": "GERGANA",
        "authorized_official_middle_name": "DAMIANOVA",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "864-908-6372",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "SC",
            "license": "1223",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "SC",
            "license": "5825",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "SC",
            "license": "30719",
            "primary": true
        },
        {
            "code": "2084P0805X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Geriatric Psychiatry",
            "state": "SC",
            "license": "30719",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Travelers Rest, SC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.