Healthcare Provider Details

I. General information

NPI: 1578080180
Provider Name (Legal Business Name): ALVIN MITCHELL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BREEZEWOOD COURT
COLUMBIA SC
29212
US

IV. Provider business mailing address

10 BREEZEWOOD CT
COLUMBIA SC
29212-2901
US

V. Phone/Fax

Practice location:
  • Phone: 803-363-9674
  • Fax: 803-509-8210
Mailing address:
  • Phone: 803-363-9674
  • Fax: 803-509-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number2017-54189-53078
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: