Healthcare Provider Details

I. General information

NPI: 1053419101
Provider Name (Legal Business Name): JIM A CHITMON COF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 B SOUTH MEMORIAL DR
GREENVILLE NC
27834
US

IV. Provider business mailing address

615 B SOUTH MEMORIAL DR
GREENVILLE NC
27834
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-0338
  • Fax:
Mailing address:
  • Phone: 252-752-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number02771
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: