Provider Demographics
NPI:1083491468
Name:DUVALL, GERALD L JR
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:DUVALL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 28TH AVE S APT 8
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-4841
Mailing Address - Country:US
Mailing Address - Phone:843-940-0490
Mailing Address - Fax:
Practice Address - Street 1:210 28TH AVE S APT 8
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-4841
Practice Address - Country:US
Practice Address - Phone:843-940-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13259225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist