Healthcare Provider Details

I. General information

NPI: 1770977613
Provider Name (Legal Business Name): NIKOLAY KORNEYCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S CONGRESS ST
YORK SC
29745-1836
US

IV. Provider business mailing address

1780 COMPTON BRIDGE RD
INMAN SC
29349-8482
US

V. Phone/Fax

Practice location:
  • Phone: 803-684-0035
  • Fax:
Mailing address:
  • Phone: 864-804-4510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number337700
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: