Provider Demographics
NPI:1699180133
Name:PETTIS, BRIAN (ATC, SCAT, CSCS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PETTIS
Suffix:
Gender:M
Credentials:ATC, SCAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 E OLD MARION HWY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-7418
Mailing Address - Country:US
Mailing Address - Phone:843-954-3608
Mailing Address - Fax:
Practice Address - Street 1:1411 E OLD MARION HWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-7418
Practice Address - Country:US
Practice Address - Phone:843-954-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC0349822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer