Healthcare Provider Details

I. General information

NPI: 1366283822
Provider Name (Legal Business Name): DAMIEN DONOVAN DACM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 09/17/2026
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 GRANDE DUNES N VILLAGE BLVD UNIT 8308
LONGS SC
29568
US

IV. Provider business mailing address

2740 GRANDE DUNES N VILLAGE BLVD UNIT 8308
LONGS SC
29568
US

V. Phone/Fax

Practice location:
  • Phone: 836-282-1833
  • Fax:
Mailing address:
  • Phone: 836-282-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13596
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number417
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2222
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: