Healthcare Provider Details

I. General information

NPI: 1104756345
Provider Name (Legal Business Name): CHARLES TAYLOR HUDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 REVOLUTIONARY TRL
FAIRFAX SC
29827-7109
US

IV. Provider business mailing address

333 REVOLUTIONARY TRL
FAIRFAX SC
29827-7109
US

V. Phone/Fax

Practice location:
  • Phone: 803-632-2533
  • Fax: 803-259-3250
Mailing address:
  • Phone: 803-632-2533
  • Fax: 803-259-3250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2733
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: