Healthcare Provider Details

I. General information

NPI: 1881085918
Provider Name (Legal Business Name): STAT.MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3993 MEETING STREET
LORIS SC
29569-3053
US

IV. Provider business mailing address

1209 MILLER RD
TABOR CITY NC
28463-9266
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-3008
  • Fax: 843-756-3128
Mailing address:
  • Phone: 910-840-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. HARRY NICKEY GORE JR.
Title or Position: COO
Credential:
Phone: 843-756-3008