Individual
BLAKE BANNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
971A ROBERTS DR, ELGIN, SC 29045-9087
(803) 543-2185
Mailing address
971A ROBERTS DR, ELGIN, SC 29045-9087
(803) 543-2185
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
—
SC
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
SC
Other
Enumeration date
08/28/2015
Last updated
08/28/2015
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