MEDICARE: ANTOINE MAYFIELD OWNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1134502339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINE MAYFIELD OWNER

Provider Business Mailing Address
First Line	:	1058 CHALK HILL LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-0005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3043 W STILES ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-4410
Country	:	US
Telephone Number	:	704-502-7412
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	09/30/2022

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