Healthcare Provider Details

I. General information

NPI: 1629767462
Provider Name (Legal Business Name): CLEVERT GRAHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

118 SEATON RIDGE DRIVE
BLYTHEWOOD SC
29016
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-2000
  • Fax:
Mailing address:
  • Phone: 803-587-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number8016852
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: