Healthcare Provider Details

I. General information

NPI: 1467039909
Provider Name (Legal Business Name): JAN ERIC NERUD CADC-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 BLUFF RD
COLUMBIA SC
29201-4809
US

IV. Provider business mailing address

238 RIVER CREEK DR
IRMO SC
29063-8300
US

V. Phone/Fax

Practice location:
  • Phone: 803-733-5855
  • Fax: 803-733-5892
Mailing address:
  • Phone: 404-907-7184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1469
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: