Individual
JEFFREY CHARLES LAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
520 NEWTON RD, IRMO, SC 29063-2948
(623) 695-7705
Mailing address
520 NEWTON RD, IRMO, SC 29063-2948
(623) 695-7705
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
ATR1310ATH
SC
Other
Enumeration date
08/07/2026
Last updated
08/07/2026
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