MEDICARE: BRENDA LEE SORRELLS CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224900000X	Mastectomy Fitter	CFM02296
2	222Z00000X	Orthotist	CO003119

General Provider Information

NPI Number	:	1134765167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA LEE SORRELLS CO

Provider Business Mailing Address
First Line	:	223 S HERLONG AVE STE 110
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1089
Country	:	US
Telephone Number	:	803-980-5080
Fax Number	:	803-980-5083

Provider Business Practice Location Address
First Line	:	223 S HERLONG AVE STE 110
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1089
Country	:	US
Telephone Number	:	803-980-5080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2019
Last Update Date	:	05/31/2022

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