Provider Demographics
NPI:1740504158
Name:HESSELGRAVE, ALLEN DEAN (CPO)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:DEAN
Last Name:HESSELGRAVE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRUSHY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-1006
Mailing Address - Country:US
Mailing Address - Phone:864-989-1946
Mailing Address - Fax:864-989-1947
Practice Address - Street 1:1 BRUSHY MEADOWS DR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1006
Practice Address - Country:US
Practice Address - Phone:864-989-1946
Practice Address - Fax:864-989-1947
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCPO001909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCPO001909OtherABC