Basic Information
| Provider Information | |||||||||
| NPI: | 1386997591 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAMBERG JOB CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3310 MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291151466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035316900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19 JOB CORPS AVE | ||||||||
| Address2: | |||||||||
| City: | BAMBERG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290031606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032455101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRUNSON | ||||||||
| AuthorizedOfficialFirstName: | LEON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8035316900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH CENTERS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.