Healthcare Provider Details

I. General information

NPI: 1134944622
Provider Name (Legal Business Name): SAMUEL JONES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3875
US

IV. Provider business mailing address

104 DECKER DR
GREENWOOD SC
29646-9469
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: