Provider Demographics
NPI:1104223148
Name:DICKINSON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DICKINSON
Suffix:
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 1:1100 PULASKI ST
Mailing Address - Street 2:APT 225
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3644
Mailing Address - Country:US
Mailing Address - Phone:609-602-3207
Mailing Address - Fax:
Practice Address - Street 1:7467 SAINT ANDREWS RD
Practice Address - Street 2:#9
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2875
Practice Address - Country:US
Practice Address - Phone:609-602-3207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer