Healthcare Provider Details

I. General information

NPI: 1457831539
Provider Name (Legal Business Name): RONALD CAUDILL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD FL 5
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-4411
  • Fax: 864-455-4480
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22130
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: