Healthcare Provider Details

I. General information

NPI: 1053764977
Provider Name (Legal Business Name): MARK EDWARD BOULDEN JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 N FRASER ST
GEORGETOWN SC
29440-6418
US

IV. Provider business mailing address

2185 N FRASER ST
GEORGETOWN SC
29440-6418
US

V. Phone/Fax

Practice location:
  • Phone: 843-527-1800
  • Fax: 843-527-6528
Mailing address:
  • Phone: 843-527-1800
  • Fax: 843-527-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1667
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: