Healthcare Provider Details

I. General information

NPI: 1043282916
Provider Name (Legal Business Name): SCOTT WILLIAM GARDNER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 KILLIAN AVE ATTN: OHWS GROUP
SHAW AFB SC
29152
US

IV. Provider business mailing address

119 SAUSAGE LN
WEST COLUMBIA SC
29170-2462
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-3719
  • Fax:
Mailing address:
  • Phone: 803-586-4944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1119
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: