Provider Demographics
NPI:1265840375
Name:FISHBURNE, DARRYLE
Entity Type:Individual
Prefix:
First Name:DARRYLE
Middle Name:
Last Name:FISHBURNE
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 1:910 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-4130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4401 BELLE OAKS DR
Practice Address - Street 2:SUITE 280
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8537
Practice Address - Country:US
Practice Address - Phone:866-571-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3065227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered