Provider Demographics
NPI:1821888405
Name:CARROLL, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CARROLL
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 1:118 ARUNDEL DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-1664
Mailing Address - Country:US
Mailing Address - Phone:803-614-5823
Mailing Address - Fax:
Practice Address - Street 1:118 ARUNDEL DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1664
Practice Address - Country:US
Practice Address - Phone:803-614-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC244972163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse