Healthcare Provider Details

I. General information

NPI: 1346385952
Provider Name (Legal Business Name): BRADLEY EUGENE YEARGIN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 HARDEN STREET EXT SUITE 100
COLUMBIA SC
29203-6842
US

IV. Provider business mailing address

3250 HARDEN STREET EXT SUITE 100
COLUMBIA SC
29203-6842
US

V. Phone/Fax

Practice location:
  • Phone: 803-606-3067
  • Fax:
Mailing address:
  • Phone: 803-606-3067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000294
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1358
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: