=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225406960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JIM NASIM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2015
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 WEST DURST AVENUE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-576-7169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 WEST DURST AVENUE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-576-7169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HR MANAGER
-----------------------------------------------------
Name | BARBARA MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-382-3536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 2881
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2881
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------