MEDICARE: JONATHAN DANIEL WHITTEN BOCO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist	C52190	SC

General Provider Information

NPI Number	:	1093287138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN DANIEL WHITTEN BOCO

Provider Business Mailing Address
First Line	:	315 LOOPER RD
Second Line	:
City	:	PELZER
State	:	SC
Zip	:	29669-1042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 CLAIR DR STE B
Second Line	:
City	:	PIEDMONT
State	:	SC
Zip	:	29673-6401
Country	:	US
Telephone Number	:	864-252-4377
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2018
Last Update Date	:	01/23/2023

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