Provider Demographics
NPI:1215398417
Name:PARKER, MARIO (LMT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 BROAD RIVER RD
Mailing Address - Street 2:APT N-1
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4710
Mailing Address - Country:US
Mailing Address - Phone:803-201-5474
Mailing Address - Fax:
Practice Address - Street 1:1216 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-7619
Practice Address - Country:US
Practice Address - Phone:803-865-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist