Provider Demographics
NPI:1568448348
Name:SPROUSE, JOHN S
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:SPROUSE
Suffix:
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 1:1513 MONTAGUE AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-9030
Mailing Address - Country:US
Mailing Address - Phone:864-229-3997
Mailing Address - Fax:864-388-9419
Practice Address - Street 1:1513 MONTAGUE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-9030
Practice Address - Country:US
Practice Address - Phone:864-229-3997
Practice Address - Fax:864-388-9419
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0613Medicaid
SC0176040001Medicare NSC
SC0176040002Medicare NSC