Provider Demographics
NPI:1578217642
Name:SIMON, KELVIN
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:SIMON
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 1:4039 CHERRY JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:SC
Mailing Address - Zip Code:29541-4214
Mailing Address - Country:US
Mailing Address - Phone:843-245-1301
Mailing Address - Fax:
Practice Address - Street 1:4039 CHERRY JOHNSON RD
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:SC
Practice Address - Zip Code:29541-4214
Practice Address - Country:US
Practice Address - Phone:843-245-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory