Healthcare Provider Details

I. General information

NPI: 1558816041
Provider Name (Legal Business Name): SHEA SKORUSA ATC, SCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 MCCRAYS MILL RD
SUMTER SC
29154-6028
US

IV. Provider business mailing address

630 BIRKDALE CIR APARTMENT #33
SUMTER SC
29154-6324
US

V. Phone/Fax

Practice location:
  • Phone: 803-481-4480
  • Fax:
Mailing address:
  • Phone: 904-651-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1669
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: