Healthcare Provider Details

I. General information

NPI: 1902483647
Provider Name (Legal Business Name): JARROD BUTLER MULLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST STE 3
MANNING SC
29102-3149
US

IV. Provider business mailing address

50 E HOSPITAL ST STE 3
MANNING SC
29102-3149
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-8828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number83645
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: