Healthcare Provider Details

I. General information

NPI: 1710517370
Provider Name (Legal Business Name): NICKOLAS GRANT SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 KEOWEE SCHOOL RD
SENECA SC
29672-6780
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-885-7129
  • Fax: 864-882-7240
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23620
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: