Provider Demographics
NPI:1245646090
Name:CALDWELL-GLOVER, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CALDWELL-GLOVER
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 1:2000 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1002
Mailing Address - Country:US
Mailing Address - Phone:803-576-2956
Mailing Address - Fax:
Practice Address - Street 1:2000 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1002
Practice Address - Country:US
Practice Address - Phone:803-576-2956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC253133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576000286OtherSC DEPT. OF HEALTH AND ENVIRONMENTAL CONTROL