Healthcare Provider Details

I. General information

NPI: 1699011973
Provider Name (Legal Business Name): RONTRELLA D ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 CAMPBELL THICKETT RD
RIDGEVILLE SC
29472-6339
US

IV. Provider business mailing address

331 CAMPBELL THICKETT RD
RIDGEVILLE SC
29472-6339
US

V. Phone/Fax

Practice location:
  • Phone: 843-821-3073
  • Fax: 843-851-8427
Mailing address:
  • Phone: 843-821-3073
  • Fax: 843-851-8427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10092
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: