Healthcare Provider Details

I. General information

NPI: 1952014318
Provider Name (Legal Business Name): SAMUEL JOHN MAYCOCK OTD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 FOREST LN STE A
CLEMSON SC
29631-2621
US

IV. Provider business mailing address

PO BOX 616
MARIETTA SC
29661-0616
US

V. Phone/Fax

Practice location:
  • Phone: 864-654-2001
  • Fax: 800-305-7112
Mailing address:
  • Phone: 864-214-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6703
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: