1912964479 NPI number — LAKE MARION PRIMARY CARE

Table of content: (NPI 1912964479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912964479 NPI number — LAKE MARION PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MARION PRIMARY CARE
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:
1912964479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 E HOSPITAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANNING
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29102-3152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-435-2529
Provider Business Mailing Address Fax Number:
803-435-4196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 E HOSPITAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANNING
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29102-3152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-435-2529
Provider Business Practice Location Address Fax Number:
803-435-4196
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
SAUNDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
803-435-2529

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  13275 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RC0000X , with the licence number: 20345 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: GP2178 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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