Healthcare Provider Details

I. General information

NPI: 1932671039
Provider Name (Legal Business Name): MS. MARY LOU BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2018
Last Update Date: 12/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 COGBURN CT
COLUMBIA SC
29229-8075
US

IV. Provider business mailing address

5 COGBURN CT
COLUMBIA SC
29229-8075
US

V. Phone/Fax

Practice location:
  • Phone: 803-771-6351
  • Fax: 843-868-8052
Mailing address:
  • Phone: 803-771-6351
  • Fax: 843-868-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License NumberIHCP-0973
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: