1184771321 NPI number — GOLDEN CORNER FAMILY PRAC

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 1184771321 NPI number — GOLDEN CORNER FAMILY PRAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN CORNER FAMILY PRAC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1184771321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 219
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST UNION
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29696-0219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-638-5402
Provider Business Mailing Address Fax Number:
864-638-6126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 N HIGHWAY 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST UNION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29696-2715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-638-5402
Provider Business Practice Location Address Fax Number:
864-638-6126
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOOKER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
864-638-5402

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 094953 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: L31366 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: L31357 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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