1326254046 NPI number — MRS. LISA JEFFUS SMITH PA

Table of content: MRS. LISA JEFFUS SMITH PA (NPI 1326254046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326254046 NPI number — MRS. LISA JEFFUS SMITH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
LISA
Provider Middle Name:
JEFFUS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
LISA
Provider Other Middle Name:
JEFFUS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326254046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 MAIN STREET AGAPE SENIOR PRIMARY CARE, INC.
Provider Second Line Business Mailing Address:
DBA AGAPE PHYSICIANS CARE
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-454-0365
Provider Business Mailing Address Fax Number:
803-404-6000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1761 PINEWOOD ROAD
Provider Second Line Business Practice Location Address:
AGAPE PHYSICIANS CARE
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-481-8591
Provider Business Practice Location Address Fax Number:
855-886-9360
Provider Enumeration Date:
05/16/2007

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:  001000182 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 1307 , 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)





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