MEDICARE: SIDNETRICE HANKERSON

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1578966040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNETRICE HANKERSON

Provider Business Mailing Address
First Line	:	1946 BROOKSTONE WAY
Second Line	:	107
City	:	ROCK HILL
State	:	SC
Zip	:	29732-2679
Country	:	US
Telephone Number	:	704-281-0416
Fax Number	:

Provider Business Practice Location Address
First Line	:	1946 BROOKSTONE WAY
Second Line	:	107
City	:	ROCK HILL
State	:	SC
Zip	:	29732-2679
Country	:	US
Telephone Number	:	704-281-0416
Fax Number	:

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

Provider Enumeration Date	:	09/29/2014
Last Update Date	:	09/29/2014

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