Provider Demographics
NPI:1942443999
Name:GODBOLD, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:GODBOLD
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 1:1928 GADDYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:HAMER
Mailing Address - State:SC
Mailing Address - Zip Code:29547-7033
Mailing Address - Country:US
Mailing Address - Phone:843-774-7132
Mailing Address - Fax:843-841-2482
Practice Address - Street 1:210 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3310
Practice Address - Country:US
Practice Address - Phone:843-774-7132
Practice Address - Fax:843-841-2482
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist