Healthcare Provider Details

I. General information

NPI: 1861894610
Provider Name (Legal Business Name): AUDREY RAVENELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 DORCHESTER RD
NORTH CHARLESTON SC
29418-5603
US

IV. Provider business mailing address

5060 DORCHESTER RD
NORTH CHARLESTON SC
29418-5603
US

V. Phone/Fax

Practice location:
  • Phone: 843-225-9053
  • Fax:
Mailing address:
  • Phone: 843-225-9053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number32402
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: