Provider Demographics
NPI:1619647336
Name:MATHIS, VIVIAN P
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:P
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 FAT BACK RD
Mailing Address - Street 2:
Mailing Address - City:DALZELL
Mailing Address - State:SC
Mailing Address - Zip Code:29040-8548
Mailing Address - Country:US
Mailing Address - Phone:803-459-7448
Mailing Address - Fax:
Practice Address - Street 1:337 FAT BACK RD
Practice Address - Street 2:
Practice Address - City:DALZELL
Practice Address - State:SC
Practice Address - Zip Code:29040-8548
Practice Address - Country:US
Practice Address - Phone:803-459-7448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker