Healthcare Provider Details

I. General information

NPI: 1023651957
Provider Name (Legal Business Name): SEAN ANTHONY MAXWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 HIGHWAY 321 BYPASS N.
WINNSBORO SC
29180
US

IV. Provider business mailing address

PO BOX 388
WINNSBORO SC
29180-0388
US

V. Phone/Fax

Practice location:
  • Phone: 803-635-2335
  • Fax: 803-653-9695
Mailing address:
  • Phone: 803-635-2335
  • Fax: 803-635-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: