Provider Demographics
NPI:1043471006
Name:JOHN SPROUSE
Entity type:Organization
Organization Name:JOHN SPROUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-229-3997
Mailing Address - Street 1:1513 MONTAGUE AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-9030
Mailing Address - Country:US
Mailing Address - Phone:864-229-3997
Mailing Address - Fax:864-388-9419
Practice Address - Street 1:1513 MONTAGUE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-9030
Practice Address - Country:US
Practice Address - Phone:864-229-3997
Practice Address - Fax:864-388-9419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDM0613Medicaid
SC0176040001Medicare NSC
SCDM0613Medicaid