Healthcare Provider Details

I. General information

NPI: 1184662124
Provider Name (Legal Business Name): MICKEY TRAVIS SIZEMORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 E NORTH ST SUITE 18
GREENVILLE SC
29615-2437
US

IV. Provider business mailing address

4200 E NORTH ST SUITE 18
GREENVILLE SC
29615-2437
US

V. Phone/Fax

Practice location:
  • Phone: 864-292-0226
  • Fax: 864-268-7022
Mailing address:
  • Phone: 864-292-0226
  • Fax: 864-268-7022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3595
License Number StateSC

VIII. Authorized Official

Name: DR. MICKEY TRAVIS SIZEMORE
Title or Position: PHYSICIAN/OWNER
Credential: D.C.
Phone: 864-292-0226