Provider Demographics
NPI:1356429344
Name:MITCHELL, GENNETTA GREER (DC)
Entity type:Individual
Prefix:DR
First Name:GENNETTA
Middle Name:GREER
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAKE CAROLINA WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:803-479-8400
Mailing Address - Fax:803-477-3174
Practice Address - Street 1:5 LAKE CAROLINA WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7561
Practice Address - Country:US
Practice Address - Phone:803-479-8400
Practice Address - Fax:803-477-3174
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007213111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX03631OtherBLUE CROSS/BLUE
NY02009832Medicaid
NYU60479Medicare UPIN
NY02009832Medicaid