Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 08425 | IA |
N | 213EG0000X | General Practice | 08425 | IA |
N | 1223G0001X | General Practice | 6983 | SC |
N | 213EG0000X | General Practice | 6983 | SC |
Y | 1223G0001X | General Practice | 9269 | NC |
Y | 213EG0000X | General Practice | 9269 | NC |
NPI | 1003947615 |
---|---|
Provider Name | Dr. Chad Jeremy Vanourny |
First Address | Lake Wylie, SC 29710-9230 |
Second Address | Charlotte, NC 28278 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2007 |
Last Update Date | 14/08/2018 |