MEDICARE: TERRENCE STEVENS

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	172A00000X	Driver	045019704	GA

General Provider Information

NPI Number	:	1649692625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRENCE STEVENS

Provider Business Mailing Address
First Line	:	PO BOX 1171
Second Line	:
City	:	RED OAK
State	:	GA
Zip	:	30272-1171
Country	:	US
Telephone Number	:	678-768-5614
Fax Number	:	404-506-9074

Provider Business Practice Location Address
First Line	:	5639 DEERFIELD CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-3768
Country	:	US
Telephone Number	:	678-768-5614
Fax Number	:	404-506-9074

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

Provider Enumeration Date	:	01/10/2014
Last Update Date	:	01/10/2014

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Directions to “ TERRENCE STEVENS ” Practice Location

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