Healthcare Provider Details

I. General information

NPI: 1982156774
Provider Name (Legal Business Name): AMANDA MOON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 N HIGHWAY 17 SUITE 220
MT PLEASANT SC
29466-8227
US

IV. Provider business mailing address

3510 N HIGHWAY 17 SUITE 220
MT PLEASANT SC
29466-8227
US

V. Phone/Fax

Practice location:
  • Phone: 854-853-3474
  • Fax:
Mailing address:
  • Phone: 854-853-3474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1531
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: