Provider Demographics
NPI:1114393337
Name:STACHECKI, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:STACHECKI
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 1:204 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-3218
Mailing Address - Country:US
Mailing Address - Phone:843-708-8856
Mailing Address - Fax:
Practice Address - Street 1:204 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-3218
Practice Address - Country:US
Practice Address - Phone:843-708-8856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP47764164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse