Provider Demographics
NPI:1417497314
Name:CHAVIS, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:CHAVIS
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 1:7223 KENDALLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6219
Mailing Address - Country:US
Mailing Address - Phone:803-357-1105
Mailing Address - Fax:
Practice Address - Street 1:7223 KENDALLWOOD CT
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6219
Practice Address - Country:US
Practice Address - Phone:803-357-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC364SHO200X320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC364SHO200XMedicaid