Healthcare Provider Details

I. General information

NPI: 1275676892
Provider Name (Legal Business Name): JORGE ANTONIO PERDOMO LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 GREENVILLE DRIVE
WILLIAMSTON SC
29697
US

IV. Provider business mailing address

135 CRYSTAL DR
DUNCAN SC
29334-9320
US

V. Phone/Fax

Practice location:
  • Phone: 864-847-1818
  • Fax: 864-847-5706
Mailing address:
  • Phone: 864-439-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: