Healthcare Provider Details

I. General information

NPI: 1205327053
Provider Name (Legal Business Name): TERESA GUMINO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 05/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SMYTHE ST
GREENVILLE SC
29611-3567
US

IV. Provider business mailing address

5000 OLD BUNCOMBE RD STE 27-213
GREENVILLE SC
29617-8208
US

V. Phone/Fax

Practice location:
  • Phone: 864-360-8486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8558
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: