Provider Demographics
NPI:1750861571
Name:FLOOD, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FLOOD
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 1:1910 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-9156
Mailing Address - Country:US
Mailing Address - Phone:803-347-3930
Mailing Address - Fax:
Practice Address - Street 1:1910 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-9156
Practice Address - Country:US
Practice Address - Phone:803-347-3930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83-1556655253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC83-1556655Medicaid
SC83-1556655OtherPRIVATE INSURACE CARRIERS
SC83-1556655OtherPRIVATE INSURANCE