Provider Demographics
NPI:1629715180
Name:SHIVERS, TERESA YOLANDA (LICENSES)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:YOLANDA
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:LICENSES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 UNCLE BUD RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-8130
Mailing Address - Country:US
Mailing Address - Phone:803-707-7016
Mailing Address - Fax:
Practice Address - Street 1:1124 UNCLE BUD RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-8130
Practice Address - Country:US
Practice Address - Phone:803-707-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42D2254381261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center