Healthcare Provider Details

I. General information

NPI: 1093301103
Provider Name (Legal Business Name): SHANNON STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10125 DORCHESTER RD STE A7
SUMMERVILLE SC
29485-8548
US

IV. Provider business mailing address

144 BEN RUFUS DR
GEORGETOWN SC
29440-8753
US

V. Phone/Fax

Practice location:
  • Phone: 843-520-9934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number73192
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: