Provider Demographics
NPI:1497305841
Name:MINTZ, KATINA
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 CHANDLER CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6464
Mailing Address - Country:US
Mailing Address - Phone:843-319-3708
Mailing Address - Fax:
Practice Address - Street 1:1314 CHANDLER CIR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6464
Practice Address - Country:US
Practice Address - Phone:843-319-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCG122094171W00000X, 171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
No171W00000XOther Service ProvidersContractor