Provider Demographics
NPI:1043274707
Name:ETHERIDGE, JON LLOYD (DC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:LLOYD
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7807
Mailing Address - Country:US
Mailing Address - Phone:843-875-2268
Mailing Address - Fax:843-875-2267
Practice Address - Street 1:1711 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7807
Practice Address - Country:US
Practice Address - Phone:843-875-2268
Practice Address - Fax:843-875-2267
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1243111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1243Medicaid