Healthcare Provider Details

I. General information

NPI: 1851505713
Provider Name (Legal Business Name): SANDRA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 TURTLE CREEK DR
PAWLEYS ISLAND SC
29585-8288
US

IV. Provider business mailing address

178 TURTLE CREEK DR
PAWLEYS ISLAND SC
29585-8288
US

V. Phone/Fax

Practice location:
  • Phone: 843-235-3240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: