Healthcare Provider Details

I. General information

NPI: 1134502339
Provider Name (Legal Business Name): ANTOINE MAYFIELD OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3043 W STILES ST
PHILADELPHIA PA
19121-4410
US

IV. Provider business mailing address

1058 CHALK HILL LN
CHARLOTTE NC
28214-0005
US

V. Phone/Fax

Practice location:
  • Phone: 704-502-7412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: