Provider Information for 1073069597
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DERRICK FOWLER
Sex: Male
NPI: 1073069597
Last Updated: 2016-08-26
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1073069597 | ||||||||
| Enumeration Date | 2016-08-26 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 199 S HERLONG AVE ROCK HILL, SC 29732-1186 United States Phone: 803-324-1800 | Fax: | ||||||||
| Primary Practice Address | 199 S HERLONG AVE ROCK HILL, SC 29732-1186 United States Phone: 803-324-1800 | Fax: | ||||||||
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