Healthcare Provider Details

I. General information

NPI: 1386072940
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 UNION BLVD
UNION SC
29379-2940
US

IV. Provider business mailing address

539 UNION BLVD
UNION SC
29379-2940
US

V. Phone/Fax

Practice location:
  • Phone: 864-466-2118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number5425
License Number StateSC

VIII. Authorized Official

Name: HOLLY MATHIS
Title or Position: STAFFING MANAGER
Credential:
Phone: 866-571-2700