Provider Demographics
NPI:1346485828
Name:TATE, CONNIE E (LMT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:E
Last Name:TATE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PETE HOLLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-1155
Mailing Address - Country:US
Mailing Address - Phone:864-242-3707
Mailing Address - Fax:
Practice Address - Street 1:17 LAWTON AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2305
Practice Address - Country:US
Practice Address - Phone:864-232-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4898171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor