Healthcare Provider Details

I. General information

NPI: 1669213716
Provider Name (Legal Business Name): THEORESA BUNCH GIPLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 HARRISON RD
LADSON SC
29456-5502
US

IV. Provider business mailing address

1069 HARRISON RD
LADSON SC
29456-5502
US

V. Phone/Fax

Practice location:
  • Phone: 854-273-8051
  • Fax:
Mailing address:
  • Phone: 854-273-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS.13651
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: