Provider Demographics
NPI:1497221253
Name:GIST, KEVIN JAMES II
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:GIST
Suffix:II
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 1:1078 GIST DR
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-5775
Mailing Address - Country:US
Mailing Address - Phone:803-825-7553
Mailing Address - Fax:
Practice Address - Street 1:1078 GIST DR
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-5775
Practice Address - Country:US
Practice Address - Phone:803-825-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer