Provider Demographics
NPI:1275891673
Name:VICKERS, JOHNATHAN C (CRT)
Entity Type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:C
Last Name:VICKERS
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 CREIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-3623
Mailing Address - Country:US
Mailing Address - Phone:864-438-6405
Mailing Address - Fax:
Practice Address - Street 1:619 CREIGHTON DR
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-3623
Practice Address - Country:US
Practice Address - Phone:864-438-6405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRCP32472278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health