Provider Demographics
NPI:1982214599
Name:DAMON, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:DAMON
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:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29597-0064
Mailing Address - Country:US
Mailing Address - Phone:843-446-8940
Mailing Address - Fax:
Practice Address - Street 1:320 58TH AVE N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-1122
Practice Address - Country:US
Practice Address - Phone:843-446-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-09783747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCIHCP-0978OtherSC DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL