Healthcare Provider Details

I. General information

NPI: 1194233635
Provider Name (Legal Business Name): COREY RANSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 WILDWOOD CENTRE DR
COLUMBIA SC
29229-8420
US

IV. Provider business mailing address

181 W PROFESSIONAL PARK CT STE 1
BOWLING GREEN KY
42104-3250
US

V. Phone/Fax

Practice location:
  • Phone: 803-999-3752
  • Fax:
Mailing address:
  • Phone: 270-777-9283
  • Fax: 270-777-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-34894
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: