1124359310 NPI number — DR. STEFANIE SUZANE ERVIN D.C.

Table of content: DR. STEFANIE SUZANE ERVIN D.C. (NPI 1124359310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124359310 NPI number — DR. STEFANIE SUZANE ERVIN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERVIN
Provider First Name:
STEFANIE
Provider Middle Name:
SUZANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FUESS
Provider Other First Name:
STEFANIE
Provider Other Middle Name:
SUZANE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124359310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1154 KINGS BOTTOM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29715-5604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-817-5831
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8040 PROVIDENCE RD STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-9762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-817-5831
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3987 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 3822 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 4377 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)