| |
1 Wellness Blvd Ste 108, Irmo, SC 29063-2872 | |
(803) 765-1919 | |
(803) 849-8875 |
Full Name | |
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Type | Facility |
Speciality | Audiologist |
Location | 1 Wellness Blvd Ste 108, Irmo, South Carolina |
Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
Identifier | Type | State | Issuer |
---|---|---|---|
1770094161 | NPI | - | NPPES |
1063599512 | Other | PROVIDER NPI | |
SA0061 | Medicaid | SC |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
231H00000X | Audiologist | 1067 (South Carolina) | Primary |
261QH0700X | Clinic/center - Hearing And Speech | (* (Not Available)) | Secondary |
Provider Name | Kenneth Johns |
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Provider Type | Practitioner - Qualified Audiologist |
Provider Identifiers | NPI Number: 1063599512 PECOS PAC ID: 4789695339 Enrollment ID: I20111206000864 |
Mailing Address | Practice Location Address |
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851 Broken Sound Pkwy Nw Ste 120, Boca Raton, FL 33487-3638 Ph: (561) 367-1623 | 1 Wellness Blvd Ste 108, Irmo, SC 29063-2872 Ph: (803) 765-1919 |