Provider Demographics
NPI:1568818284
Name:HEALTHSTAT ONSITE CLINIC SAGE COTTON BLOSSOM
Entity Type:Organization
Organization Name:HEALTHSTAT ONSITE CLINIC SAGE COTTON BLOSSOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-529-6161
Mailing Address - Street 1:4651 CHARLOTTE PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1956
Mailing Address - Country:US
Mailing Address - Phone:704-529-6161
Mailing Address - Fax:
Practice Address - Street 1:295 BROADCAST DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4712
Practice Address - Country:US
Practice Address - Phone:704-529-6161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty