Healthcare Provider Details

I. General information

NPI: 1245685437
Provider Name (Legal Business Name): JERRY CUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PALMETTO PARK BLVD
LEXINGTON SC
29072-7968
US

IV. Provider business mailing address

108 PALMETTO PARK BLVD
LEXINGTON SC
29072-7968
US

V. Phone/Fax

Practice location:
  • Phone: 803-995-1500
  • Fax: 803-808-5392
Mailing address:
  • Phone: 803-995-1500
  • Fax: 803-808-5392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: