Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | STUDENT | SC |
Y | 213ES0000X | Sports Medicine | STUDENT | SC |
NPI | 1366906281 |
---|---|
Provider Name | Olivia Forrest |
First Address | Rock Hill, SC 29730-3698 |
Second Address | Rock Hill, SC 29733-7001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2019 |
Last Update Date | 24/01/2019 |