Healthcare Provider Details

I. General information

NPI: 1679688907
Provider Name (Legal Business Name): JEREMY WILLIAM SKOOG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 TOY ST
GREENVILLE SC
29601-3122
US

IV. Provider business mailing address

9 TOY ST
GREENVILLE SC
29601-3122
US

V. Phone/Fax

Practice location:
  • Phone: 864-251-5410
  • Fax: 864-236-4918
Mailing address:
  • Phone: 864-251-5410
  • Fax: 864-236-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5127
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: