MEDICARE: MR. IAN MICHAEL SOPER

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	225X00000X	Occupational Therapist	.5749	SC

General Provider Information

NPI Number	:	1801428750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IAN MICHAEL SOPER

Provider Business Mailing Address
First Line	:	101 SPRING LAKES DR APT 401
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31407-3509
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 LEMON GRASS CT
Second Line	:
City	:	HILTON HEAD ISLAND
State	:	SC
Zip	:	29928-3022
Country	:	US
Telephone Number	:	843-341-7300
Fax Number	:

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

Provider Enumeration Date	:	02/09/2020
Last Update Date	:	02/09/2020

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