1528362621 NPI number — LAKE MURRAY PAIN AND REHAB

Table of content: (NPI 1528362621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528362621 NPI number — LAKE MURRAY PAIN AND REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE MURRAY PAIN AND REHAB
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:
1528362621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 COLUMBIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAPIN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29036-9424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-345-0334
Provider Business Mailing Address Fax Number:
803-345-0335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 COLUMBIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPIN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29036-9424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-345-0334
Provider Business Practice Location Address Fax Number:
803-345-0335
Provider Enumeration Date:
01/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KROLL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DOCTOR/MEDICAL DIRECTOR
Authorized Official Telephone Number:
803-345-0334

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  7485 , 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)





Copyright © 2007-2025 www.npivalidator.com