Provider Demographics
NPI:1093937401
Name:BALLARD, MICHAEL J (MS ATC, PES)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BALLARD
Suffix:
Gender:M
Credentials:MS ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 WHIRLAWAY CT
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-6700
Mailing Address - Country:US
Mailing Address - Phone:803-684-7850
Mailing Address - Fax:
Practice Address - Street 1:1625 HIGHWAY 55 E
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-8551
Practice Address - Country:US
Practice Address - Phone:803-222-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer