Provider Demographics
NPI:1700848959
Name:FANTINO, VALERIE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:MARIE
Last Name:FANTINO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001-A PHYSICIANS DR.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-571-1020
Mailing Address - Fax:843-573-0788
Practice Address - Street 1:1001-A PHYSICIANS DR.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-571-1020
Practice Address - Fax:843-573-0788
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1009111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH363Medicaid
SCGCH363Medicaid
SCT235464010Medicare PIN