Provider Demographics
NPI:1932192671
Name:SHADBOLT, JERRY (ATC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:SHADBOLT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:SHADBOLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:3145 TAMARAH WAY
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-9556
Mailing Address - Country:US
Mailing Address - Phone:803-778-5223
Mailing Address - Fax:
Practice Address - Street 1:1215 ALICE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1905
Practice Address - Country:US
Practice Address - Phone:803-778-5223
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer