Healthcare Provider Details

I. General information

NPI: 1558669358
Provider Name (Legal Business Name): JEREMY THOMAS PONDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2011
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 VERA RD STE A
LEXINGTON SC
29072-3756
US

IV. Provider business mailing address

736 SHADOWBROOK DR
COLUMBIA SC
29210-3751
US

V. Phone/Fax

Practice location:
  • Phone: 803-575-0468
  • Fax: 803-728-3224
Mailing address:
  • Phone: 803-575-0468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number638
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number638
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006090
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: