1720363773 NPI number — MRS. BRITTANY LONG LOVELACE PA - C

Table of content: MRS. BRITTANY LONG LOVELACE PA - C (NPI 1720363773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720363773 NPI number — MRS. BRITTANY LONG LOVELACE PA - C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVELACE
Provider First Name:
BRITTANY
Provider Middle Name:
LONG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA - C
Provider Gender Code:
F

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:
1720363773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSPERITY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29127-0630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-364-4852
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N WHEELER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSPERITY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29127-9332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-364-4852
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2011

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: 363AM0700X , with the licence number:  PA1709 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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