Healthcare Provider Details

I. General information

NPI: 1780028290
Provider Name (Legal Business Name): SHANE ENSCOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 SCENIC VIEW RD
CHESNEE SC
29323-9434
US

IV. Provider business mailing address

223 SCENIC VIEW RD
CHESNEE SC
29323-9434
US

V. Phone/Fax

Practice location:
  • Phone: 864-357-7127
  • Fax:
Mailing address:
  • Phone: 864-357-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2700
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: