Provider Demographics
NPI:1114130663
Name:BRINTON, TAVISH (LM, CPM)
Entity Type:Individual
Prefix:
First Name:TAVISH
Middle Name:
Last Name:BRINTON
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 CHARLES TOWN RD
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-9670
Mailing Address - Country:US
Mailing Address - Phone:803-894-3829
Mailing Address - Fax:
Practice Address - Street 1:1644 CHARLES TOWN RD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-9670
Practice Address - Country:US
Practice Address - Phone:803-894-3829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSCDHEC MW003176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLM0004Medicaid