Healthcare Provider Details

I. General information

NPI: 1245620418
Provider Name (Legal Business Name): SUSAN MORTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 HAMPTON ST
COLUMBIA SC
29204-1002
US

IV. Provider business mailing address

2000 HAMPTON ST
COLUMBIA SC
29204-1002
US

V. Phone/Fax

Practice location:
  • Phone: 803-576-2764
  • Fax:
Mailing address:
  • Phone: 803-576-2764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1215
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: