Healthcare Provider Details

I. General information

NPI: 1629588363
Provider Name (Legal Business Name): HEALTHSTAT ONSITE CLINIC PARKDALE PLANT 40
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 ASCAUGA LAKE RD
GRANITEVILLE SC
29829-3528
US

IV. Provider business mailing address

4651 CHARLOTTE PARK DR STE 300
CHARLOTTE NC
28217-1916
US

V. Phone/Fax

Practice location:
  • Phone: 803-663-3827
  • Fax:
Mailing address:
  • Phone: 704-935-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546