Provider Demographics
NPI:1144906918
Name:WITHERSPOON, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 OPHELIA WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-6784
Mailing Address - Country:US
Mailing Address - Phone:704-299-6382
Mailing Address - Fax:
Practice Address - Street 1:5033 DICK POND RD UNIT A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-9680
Practice Address - Country:US
Practice Address - Phone:843-220-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)