Healthcare Provider Details

I. General information

NPI: 1679712137
Provider Name (Legal Business Name): JERRY W O'NEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 LANNEAU DR SUITE 2A, 1990 AUGUSTA STREET
GREENVILLE SC
29605-1708
US

IV. Provider business mailing address

1990 AUGUSTA ST STE 2A
GREENVILLE SC
29605-2997
US

V. Phone/Fax

Practice location:
  • Phone: 864-232-3307
  • Fax: 864-232-3308
Mailing address:
  • Phone: 864-232-3307
  • Fax: 864-232-3308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: