Healthcare Provider Details

I. General information

NPI: 1003186404
Provider Name (Legal Business Name): JORDAN BROWN OATES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 PINEHAVEN STREET EXT
LAURENS SC
29360-2672
US

IV. Provider business mailing address

109 HUDDERS CREEK WAY
SIMPSONVILLE SC
29680-3543
US

V. Phone/Fax

Practice location:
  • Phone: 864-984-6584
  • Fax: 864-984-6464
Mailing address:
  • Phone: 864-360-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2707
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: