Healthcare Provider Details

I. General information

NPI: 1679419535
Provider Name (Legal Business Name): SHELTON T TYLER MOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E MARTINTOWN RD STE 6
NORTH AUGUSTA SC
29841-4239
US

IV. Provider business mailing address

725 E MARTINTOWN RD STE 6
NORTH AUGUSTA SC
29841-4239
US

V. Phone/Fax

Practice location:
  • Phone: 839-839-5422
  • Fax:
Mailing address:
  • Phone: 839-839-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0901X
TaxonomyDiplomate Laboratory Management Specialist/Technologist
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: