Provider Demographics
NPI:1518386192
Name:BYRD, BRENDA BROWN
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:BROWN
Last Name:BYRD
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 1:3615 HIGHWAY 246 N
Mailing Address - Street 2:
Mailing Address - City:HODGES
Mailing Address - State:SC
Mailing Address - Zip Code:29653-9197
Mailing Address - Country:US
Mailing Address - Phone:864-374-3541
Mailing Address - Fax:
Practice Address - Street 1:1736 MAIN ST S
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4124
Practice Address - Country:US
Practice Address - Phone:864-942-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23853261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC23853Medicaid