Healthcare Provider Details

I. General information

NPI: 1912651647
Provider Name (Legal Business Name): ONE SOURCE INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601A W LUCAS ST
FLORENCE SC
29501-1225
US

IV. Provider business mailing address

3202 W FOREST LAKE DR
FLORENCE SC
29501-8267
US

V. Phone/Fax

Practice location:
  • Phone: 843-992-7604
  • Fax:
Mailing address:
  • Phone: 843-992-7604
  • Fax: 843-799-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER M EVANS
Title or Position: OWNER
Credential: DC
Phone: 843-992-7604