MEDICARE: KELVIN SIMON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1578217642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELVIN SIMON

Provider Business Mailing Address
First Line	:	4039 CHERRY JOHNSON RD
Second Line	:
City	:	EFFINGHAM
State	:	SC
Zip	:	29541-4214
Country	:	US
Telephone Number	:	843-245-1301
Fax Number	:

Provider Business Practice Location Address
First Line	:	4039 CHERRY JOHNSON RD
Second Line	:
City	:	EFFINGHAM
State	:	SC
Zip	:	29541-4214
Country	:	US
Telephone Number	:	843-245-1301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	02/08/2022

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