Provider Demographics
NPI:1922803790
Name:AVERY, JOHN MICHAEL
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:AVERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HIGHWAY 248 S
Mailing Address - Street 2:
Mailing Address - City:NINETY SIX
Mailing Address - State:SC
Mailing Address - Zip Code:29666-8611
Mailing Address - Country:US
Mailing Address - Phone:864-910-5320
Mailing Address - Fax:
Practice Address - Street 1:1102 HIGHWAY 248 S
Practice Address - Street 2:
Practice Address - City:NINETY SIX
Practice Address - State:SC
Practice Address - Zip Code:29666-8611
Practice Address - Country:US
Practice Address - Phone:864-910-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist