Healthcare Provider Details

I. General information

NPI: 1164033742
Provider Name (Legal Business Name): ANTONIO LAMAR RIVERS HAIR LOSS SPECIALIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 W SURREY DR
NORTH CHARLESTON SC
29405-5513
US

IV. Provider business mailing address

2702 W SURREY DR
NORTH CHARLESTON SC
29405-5513
US

V. Phone/Fax

Practice location:
  • Phone: 843-224-3574
  • Fax:
Mailing address:
  • Phone: 843-224-3574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number2677
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: