Provider Demographics
NPI:1629085980
Name:SPELL, JEFFREY LANIER (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LANIER
Last Name:SPELL
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 S PENDLETON ST
Mailing Address - Street 2:STE B
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3047
Mailing Address - Country:US
Mailing Address - Phone:864-855-7030
Mailing Address - Fax:864-855-7019
Practice Address - Street 1:227 S PENDLETON ST
Practice Address - Street 2:STE B
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3047
Practice Address - Country:US
Practice Address - Phone:864-855-7030
Practice Address - Fax:864-855-7019
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT 007458225100000X
SC5178225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA726617849AMedicaid
GAP60664Medicare UPIN
GA65BBBSZMedicare ID - Type Unspecified
GA726617849AMedicaid
SCQ358216600Medicare UPIN