Healthcare Provider Details

I. General information

NPI: 1497153506
Provider Name (Legal Business Name): ETHAN QUINN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 OLD HOWELL RD
GREENVILLE SC
29615-1969
US

IV. Provider business mailing address

536 OLD HOWELL RD
GREENVILLE SC
29615-1969
US

V. Phone/Fax

Practice location:
  • Phone: 877-508-3237
  • Fax:
Mailing address:
  • Phone: 877-508-3237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208798
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: