1437692407 NPI number — PRIME CARE OF THE LOWER PEE DEE, LLC

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 1437692407 NPI number — PRIME CARE OF THE LOWER PEE DEE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME CARE OF THE LOWER PEE DEE, LLC
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:
1437692407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 KELLEYST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-394-8274
Provider Business Mailing Address Fax Number:
843-394-1604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 KELLEY ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29560-2472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-394-8274
Provider Business Practice Location Address Fax Number:
843-394-1604
Provider Enumeration Date:
11/23/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
TYRONE
Authorized Official Middle Name:
DELMAR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
843-394-8274

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  SC 1873 , 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: CH1873 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".