Provider Demographics
NPI:1205568029
Name:BALLARD, CLEO J
Entity type:Individual
Prefix:
First Name:CLEO
Middle Name:J
Last Name:BALLARD
Suffix:
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 1:3314 N HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHEN
Mailing Address - State:SC
Mailing Address - Zip Code:29479-3322
Mailing Address - Country:US
Mailing Address - Phone:678-543-4006
Mailing Address - Fax:
Practice Address - Street 1:3314 N HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:SAINT STEPHEN
Practice Address - State:SC
Practice Address - Zip Code:29479-3322
Practice Address - Country:US
Practice Address - Phone:678-543-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007568645172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver