Provider Demographics
NPI:1790290872
Name:KAZER, AUDREY TISE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:TISE
Last Name:KAZER
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:PO BOX 1597
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-1597
Mailing Address - Country:US
Mailing Address - Phone:336-749-1015
Mailing Address - Fax:
Practice Address - Street 1:570 CENTER RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-6880
Practice Address - Country:US
Practice Address - Phone:336-749-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRC-1399310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRC-1399Medicaid