Healthcare Provider Details

I. General information

NPI: 1134467681
Provider Name (Legal Business Name): TRACY KOON SCHLICKSUP DVM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SALTERBECK CT SUITE 104
MOUNT PLEASANT SC
29466-7118
US

IV. Provider business mailing address

3400 SALTERBECK CT SUITE 104
MOUNT PLEASANT SC
29466-7118
US

V. Phone/Fax

Practice location:
  • Phone: 843-971-7774
  • Fax:
Mailing address:
  • Phone: 843-971-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3146
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: