Provider Demographics
NPI:1215460480
Name:HARGROVE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-4524
Mailing Address - Country:US
Mailing Address - Phone:843-506-4008
Mailing Address - Fax:843-627-3673
Practice Address - Street 1:312 BLOSSOM CT
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-4524
Practice Address - Country:US
Practice Address - Phone:843-506-4008
Practice Address - Fax:843-627-3673
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP34448164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse