Provider Demographics
NPI: | 1942636154 |
---|---|
Name: | HEALTHSTAT ON-SITE CLINIC/MILLIKEN MAGNOLIA |
Entity Type: | Organization |
Organization Name: | HEALTHSTAT ON-SITE CLINIC/MILLIKEN MAGNOLIA |
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: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 157 MILLIKEN RD. |
Practice Address - Street 2: | |
Practice Address - City: | BLACKSBURG |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29702 |
Practice Address - Country: | US |
Practice Address - Phone: | 864-465-2521 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-09-19 |
Last Update Date: | 2013-09-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2083P0500X | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine | Group - Single Specialty |