1679540587 NPI number — MR. CARLETON ARGO MENTZER III PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679540587 NPI number — MR. CARLETON ARGO MENTZER III PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENTZER
Provider First Name:
CARLETON
Provider Middle Name:
ARGO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679540587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-9306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-757-0676
Provider Business Mailing Address Fax Number:
843-757-0779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 BLUFFTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-7621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-757-0676
Provider Business Practice Location Address Fax Number:
843-757-0779
Provider Enumeration Date:
03/01/2006

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: 363A00000X , with the licence number:  PA.200003 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 1652 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1380PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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