Healthcare Provider Details

I. General information

NPI: 1144680596
Provider Name (Legal Business Name): SANJIN MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2016
Last Update Date: 02/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 COMMONS BLVD STE C
PIEDMONT SC
29673-7766
US

IV. Provider business mailing address

3300 N MAIN ST STE D PMB 171
ANDERSON SC
29621-4128
US

V. Phone/Fax

Practice location:
  • Phone: 864-220-9115
  • Fax: 864-220-9513
Mailing address:
  • Phone: 864-220-9115
  • Fax: 864-220-9513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number17523
License Number StateSC

VIII. Authorized Official

Name: DANA WILEY
Title or Position: PRESIDENT
Credential: MD
Phone: 864-220-9115