Healthcare Provider Details

I. General information

NPI: 1750851085
Provider Name (Legal Business Name): JACOBUS ORTHOPEDICS AND INTERVENTIONAL PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 CLAIR DR
PIEDMONT SC
29673-7771
US

IV. Provider business mailing address

118 CLAIR DR
PIEDMONT SC
29673-7771
US

V. Phone/Fax

Practice location:
  • Phone: 864-934-8787
  • Fax:
Mailing address:
  • Phone: 864-934-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EDDIE VAN BRIDGES
Title or Position: COO
Credential: DC
Phone: 864-934-8787