Healthcare Provider Details

I. General information

NPI: 1639987498
Provider Name (Legal Business Name): TERRENCE HEARON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 PAULDING AVE
BRONX NY
10466-4710
US

IV. Provider business mailing address

4164 PAULDING AVE
BRONX NY
10466-4710
US

V. Phone/Fax

Practice location:
  • Phone: 347-883-0883
  • Fax:
Mailing address:
  • Phone: 347-883-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: