Healthcare Provider Details

I. General information

NPI: 1598905440
Provider Name (Legal Business Name): MR. CHESTER LAWRENCE BUFFALO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 HECTOR WALKER RD
MANNING SC
29102-6661
US

IV. Provider business mailing address

1117 HECTOR WALKER RD
MANNING SC
29102-6661
US

V. Phone/Fax

Practice location:
  • Phone: 803-473-4888
  • Fax:
Mailing address:
  • Phone: 803-473-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: