Individual
PORTERESHICE SHUNTA BRABHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
345 AMELIA ST, FAIRFAX, SC 29827-5967
(803) 682-7110
Mailing address
345 AMELIA ST, FAIRFAX, SC 29827-5967
(803) 682-7110
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
—
—
Other
Enumeration date
03/14/2013
Last updated
03/14/2013
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