Healthcare Provider Details

I. General information

NPI: 1356652879
Provider Name (Legal Business Name): MR. MELVIN J STEPHENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105B ELIZABETHTOWN ROAD
LUMBERTON NC
28358-3107
US

IV. Provider business mailing address

2105B ELIZABETHTOWN ROAD
LUMBERTON NC
28358-3107
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-7865
  • Fax:
Mailing address:
  • Phone: 910-738-7865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number24605
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: