MEDICARE: BRADLEY EUGENE YEARGIN ATC

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	2255A2300X	Athletic Trainer	000294	CT
2	2255A2300X	Athletic Trainer	1358	SC

General Provider Information

NPI Number	:	1346385952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY EUGENE YEARGIN ATC

Provider Business Mailing Address
First Line	:	3250 HARDEN STREET EXT
Second Line	:	SUITE 100
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6842
Country	:	US
Telephone Number	:	803-606-3067
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 HARDEN STREET EXT
Second Line	:	SUITE 100
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6842
Country	:	US
Telephone Number	:	803-606-3067
Fax Number	:

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

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	11/20/2014

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