Healthcare Provider Details

I. General information

NPI: 1194885111
Provider Name (Legal Business Name): MICKEY TRAVIS SIZEMORE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
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

1241 CLINGMAN DR
FORT MILL SC
29715-0083
US

V. Phone/Fax

Practice location:
  • Phone: 864-292-0226
  • Fax: 864-268-7022
Mailing address:
  • Phone: 843-295-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR010432
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3595
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: