Provider Demographics
NPI:1518623347
Name:MOATES, JAMES SR
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:MOATES
Suffix:SR
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:PO BOX 1505
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-1505
Mailing Address - Country:US
Mailing Address - Phone:864-535-5540
Mailing Address - Fax:866-209-0069
Practice Address - Street 1:317 NEW NEELY FERRY RD STE 1
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2659
Practice Address - Country:US
Practice Address - Phone:864-535-5540
Practice Address - Fax:866-209-0069
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC008627627172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC85-1451795Medicaid