Healthcare Provider Details

I. General information

NPI: 1710374418
Provider Name (Legal Business Name): JASON BUCHANAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 DEVINE ST
COLUMBIA SC
29208-3902
US

IV. Provider business mailing address

1409 DEVINE ST
COLUMBIA SC
29208-3902
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-3667
  • Fax:
Mailing address:
  • Phone: 803-777-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number718990
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: