Healthcare Provider Details

I. General information

NPI: 1427158260
Provider Name (Legal Business Name): JEREME N VENDETTE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 05/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N HIGHWAY 81
ANDERSON SC
29621-2509
US

IV. Provider business mailing address

108 RICHFIELD DR
ANDERSON SC
29625-5666
US

V. Phone/Fax

Practice location:
  • Phone: 912-270-0103
  • Fax:
Mailing address:
  • Phone: 912-270-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000508
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2364
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: