Healthcare Provider Details

I. General information

NPI: 1699072082
Provider Name (Legal Business Name): MS. MIRIAM BARBOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 LADY ST SUITE H
COLUMBIA SC
29201-3105
US

IV. Provider business mailing address

911 LADY ST SUITE H
COLUMBIA SC
29201-3105
US

V. Phone/Fax

Practice location:
  • Phone: 803-758-5962
  • Fax:
Mailing address:
  • Phone: 803-758-5962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: