Healthcare Provider Details

I. General information

NPI: 1952742942
Provider Name (Legal Business Name): ULYESSE C EVERALL III N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 EBENEZER RD AGAPE PHYSICIANS CARE
ROCK HILL SC
29732-2336
US

IV. Provider business mailing address

1624 MAIN STREET AGAPE SENIOR PRIMARY CARE, INC., DBA AGAPE PHYSICIANS CARE
COLUMBIA SC
29201
US

V. Phone/Fax

Practice location:
  • Phone: 803-207-8200
  • Fax: 803-207-8130
Mailing address:
  • Phone: 803-454-0365
  • Fax: 803-404-6000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN18357
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: