Healthcare Provider Details

I. General information

NPI: 1710603733
Provider Name (Legal Business Name): KAYLA AKEMI WATANABE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FLEETWOOD DR
EASLEY SC
29640-2022
US

IV. Provider business mailing address

200 FLEETWOOD DR
EASLEY SC
29640-2022
US

V. Phone/Fax

Practice location:
  • Phone: 864-442-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2525
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: