Provider Demographics
NPI:1194356998
Name:COLBERT, TEVON JERELL
Entity Type:Individual
Prefix:
First Name:TEVON
Middle Name:JERELL
Last Name:COLBERT
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 1:7352 S NC HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:BOOMER
Mailing Address - State:NC
Mailing Address - Zip Code:28606-9126
Mailing Address - Country:US
Mailing Address - Phone:828-850-0619
Mailing Address - Fax:
Practice Address - Street 1:7352 S NC HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BOOMER
Practice Address - State:NC
Practice Address - Zip Code:28606-9126
Practice Address - Country:US
Practice Address - Phone:828-850-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC84-4511751OtherIRS