Provider Demographics
NPI:1366283822
Name:DONOVAN, DAMIEN (DAC)
Entity type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 BAILES RIDGE AVE APT 9-108
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-0141
Mailing Address - Country:US
Mailing Address - Phone:941-278-2920
Mailing Address - Fax:
Practice Address - Street 1:1025 BAILES RIDGE AVE APT 9-108
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-0141
Practice Address - Country:US
Practice Address - Phone:941-278-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2222171100000X
SC13596225700000X
SC417171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist