Healthcare Provider Details

I. General information

NPI: 1306620539
Provider Name (Legal Business Name): EBONY GOODSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3971 SOUTHEASTERN WAY
WEST COLUMBIA SC
29169-2442
US

IV. Provider business mailing address

2815 PEACH ST
CAYCE SC
29033-2731
US

V. Phone/Fax

Practice location:
  • Phone: 803-422-9815
  • Fax:
Mailing address:
  • Phone: 803-422-9815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: