Provider Demographics
NPI:1760739692
Name:PRINCE, JEREMY GORDON (LMT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:GORDON
Last Name:PRINCE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 118008
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-8008
Mailing Address - Country:US
Mailing Address - Phone:843-302-8845
Mailing Address - Fax:843-569-5872
Practice Address - Street 1:2500 ELMS CENTER ROAD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-302-8845
Practice Address - Fax:843-569-5872
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7197225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist