Healthcare Provider Details

I. General information

NPI: 1982309654
Provider Name (Legal Business Name): SAMANTHA MANSBERGER-DUCHESNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 W MAIN ST
GREENVILLE SC
29611-4215
US

IV. Provider business mailing address

5 W MAIN ST
GREENVILLE SC
29611-4215
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-7895
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL89763
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: