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General NPI Number Information
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NPI Number | 1194454413
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Entity Type | Individual
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Provider Name | JACKIE FITZGERALD KEY II ABOC, NCLEC, LDO
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Gender | Male
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Dates
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Enumeration Date | 06/10/2022
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Last Update Date | 01/22/2024
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Provider Practice Location Address
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Address Line | 1041 EDGEFIELD RD
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City | NORTH AUGUSTA
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State | SC
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Zip | 29860-9279
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Country | US
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Telephone | 803-613-3087
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Fax | 803-202-7293
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Provider Business Mailing Address
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Address Line | 1041 EDGEFIELD RD
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City | NORTH AUGUSTA
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State | SC
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Zip | 29860-9279
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Country | US
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Telephone | 803-613-3087
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Fax | 803-202-7293
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 1173
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License Number State | SC
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