Provider Demographics
NPI:1720131550
Name:MCDANIEL, JERRY L
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:MCDANIEL
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 1:481 DIXIE ROAD
Mailing Address - Street 2:
Mailing Address - City:SALTERS
Mailing Address - State:SC
Mailing Address - Zip Code:29590
Mailing Address - Country:US
Mailing Address - Phone:843-387-5842
Mailing Address - Fax:843-387-5840
Practice Address - Street 1:481 DIXIE ROAD
Practice Address - Street 2:
Practice Address - City:SALTERS
Practice Address - State:SC
Practice Address - Zip Code:29590
Practice Address - Country:US
Practice Address - Phone:843-387-5842
Practice Address - Fax:843-387-5840
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBS 10506171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor