Healthcare Provider Details

I. General information

NPI: 1114352143
Provider Name (Legal Business Name): HEALTHSTAT ON-SITE CLINIC/MILLIKEN CEDAR HILL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BOB LITTLE RD
JONESVILLE SC
29353-2202
US

IV. Provider business mailing address

4651 CHARLOTTE PARK DR SUITE 300
CHARLOTTE NC
28217-1956
US

V. Phone/Fax

Practice location:
  • Phone: 864-429-2704
  • Fax:
Mailing address:
  • Phone:
  • 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: WARREN HUTTON
Title or Position: COO
Credential:
Phone: 704-529-6161