Provider Demographics
NPI:1689135584
Name:MCDANIELS, CARMELITA VONCILLE
Entity Type:Individual
Prefix:
First Name:CARMELITA
Middle Name:VONCILLE
Last Name:MCDANIELS
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 1:1120 MENLO DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6552
Mailing Address - Country:US
Mailing Address - Phone:803-821-8497
Mailing Address - Fax:
Practice Address - Street 1:108 COLUMBIA NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6433
Practice Address - Country:US
Practice Address - Phone:803-821-8497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32456174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist