Provider Demographics
NPI:1164033742
Name:RIVERS, ANTONIO LAMAR (HAIR LOSS SPECIALIS)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:LAMAR
Last Name:RIVERS
Suffix:
Gender:M
Credentials:HAIR LOSS SPECIALIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 W SURREY DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-5513
Mailing Address - Country:US
Mailing Address - Phone:843-224-3574
Mailing Address - Fax:
Practice Address - Street 1:2702 W SURREY DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-5513
Practice Address - Country:US
Practice Address - Phone:843-224-3574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26771744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management