Healthcare Provider Details

I. General information

NPI: 1194752816
Provider Name (Legal Business Name): JUSTIN MONTORO SIMPSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 US HIGHWAY 321 BYP S
WINNSBORO SC
29180-6725
US

IV. Provider business mailing address

180 CHERRY HILL DR
RIDGEWAY SC
29130-8367
US

V. Phone/Fax

Practice location:
  • Phone: 803-635-1441
  • Fax:
Mailing address:
  • Phone: 803-337-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: