Healthcare Provider Details

I. General information

NPI: 1790759520
Provider Name (Legal Business Name): TERRELL L STONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HARRY C RAYSOR DR
ST MATTHEWS SC
29135-8403
US

IV. Provider business mailing address

PO BOX 638
ST MATTHEWS SC
29135-0638
US

V. Phone/Fax

Practice location:
  • Phone: 803-874-3902
  • Fax: 803-874-3905
Mailing address:
  • Phone: 803-874-3902
  • Fax: 803-874-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13583
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number42D0916819
License Number StateSC

VIII. Authorized Official

Name: TERRELL L STONE
Title or Position: OWNER
Credential: MD
Phone: 803-874-3902