=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083814438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAKTREE MEDICAL CENTRE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2007
-----------------------------------------------------
Last Update Date | 12/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 GROVE RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29605-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-404-3096
-----------------------------------------------------
Fax | 864-404-3183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 484
-----------------------------------------------------
City | EASLEY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29641-0484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-855-1633
-----------------------------------------------------
Fax | 864-855-1323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DANIEL A. MCCOLLUM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 864-855-1633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------