Provider Demographics
NPI:1720343007
Name:DE MAILLY, JOHN SIMONS (ATC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SIMONS
Last Name:DE MAILLY
Suffix:
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 1:604 DAWSONS PARK WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-1929
Mailing Address - Country:US
Mailing Address - Phone:803-917-0571
Mailing Address - Fax:
Practice Address - Street 1:604 DAWSONS PARK WAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-1929
Practice Address - Country:US
Practice Address - Phone:803-917-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer