Healthcare Provider Details

I. General information

NPI: 1003396029
Provider Name (Legal Business Name): MR. ANDY BOSTICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N MAIN ST
MARION SC
29571-2517
US

IV. Provider business mailing address

317 HUTCHINSON AVE
FLORENCE SC
29505-3518
US

V. Phone/Fax

Practice location:
  • Phone: 843-423-1811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: