Provider Demographics
NPI:1386049500
Name:HEDSTROM, ROBERT STANTON JR (ATC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:STANTON
Last Name:HEDSTROM
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-5013
Mailing Address - Country:US
Mailing Address - Phone:843-714-8403
Mailing Address - Fax:
Practice Address - Street 1:751 BRUCE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-5013
Practice Address - Country:US
Practice Address - Phone:843-714-8403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
030402062OtherBOC
SC612OtherDHEC