Healthcare Provider Details

I. General information

NPI: 1891301156
Provider Name (Legal Business Name): TYS CRANIAL PROTHESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S MEMORIAL DR STE 3B
GREENVILLE NC
27834-5031
US

IV. Provider business mailing address

2400 S MEMORIAL DR STE 3B
GREENVILLE NC
27834-5031
US

V. Phone/Fax

Practice location:
  • Phone: 252-814-7136
  • Fax: 252-302-4975
Mailing address:
  • Phone: 252-814-7136
  • Fax: 252-302-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: TIJAQUANIA GARDNER
Title or Position: OWNER
Credential:
Phone: 252-814-7136