Provider Demographics
NPI:1932492535
Name:ASHLEY, BERNUM BENJAMIN III
Entity Type:Individual
Prefix:
First Name:BERNUM
Middle Name:BENJAMIN
Last Name:ASHLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9464
Mailing Address - Country:US
Mailing Address - Phone:864-486-9585
Mailing Address - Fax:
Practice Address - Street 1:125 MALLARD DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:SC
Practice Address - Zip Code:29369-9464
Practice Address - Country:US
Practice Address - Phone:864-486-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist