Basic Information
| Provider Information | |||||||||
| NPI: | 1760739692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 118008 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294238008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433028845 | ||||||||
| FaxNumber: | 8435695872 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ELMS CENTER ROAD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433028845 | ||||||||
| FaxNumber: | 8435695872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 7197 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.