Provider Demographics
NPI:1104198118
Name:EVERETT, THOMAS C SR
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:EVERETT
Suffix:SR
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 1:3599 MEADOWDALE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31606-9612
Mailing Address - Country:US
Mailing Address - Phone:229-412-7884
Mailing Address - Fax:
Practice Address - Street 1:3599 MEADOWDALE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31606-9612
Practice Address - Country:US
Practice Address - Phone:229-412-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver