Healthcare Provider Details

I. General information

NPI: 1972243137
Provider Name (Legal Business Name): TYLER RAEFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11082 N RADIO STATION RD
SENECA SC
29678-1142
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-2314
  • Fax: 864-882-3677
Mailing address:
  • Phone: 864-522-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL87633
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94696
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: