Healthcare Provider Details

I. General information

NPI: 1215049366
Provider Name (Legal Business Name): ADAPTIVE MEDICAL UPSTATE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 LAWRENCE ST
LYMAN SC
29365-1637
US

IV. Provider business mailing address

48 LAWRENCE ST
LYMAN SC
29365-1637
US

V. Phone/Fax

Practice location:
  • Phone: 864-472-5541
  • Fax: 864-472-5564
Mailing address:
  • Phone: 864-472-5541
  • Fax: 864-472-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateSC

VIII. Authorized Official

Name: MR. GREG TUCKER
Title or Position: PRESIDENT
Credential:
Phone: 864-472-5541