1770908261 NPI number — COLONIAL FAMILY PRACTICE, LLC

Table of content: (NPI 1770908261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770908261 NPI number — COLONIAL FAMILY PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL FAMILY PRACTICE, 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:
6
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:
1770908261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 BROAD ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-4167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-773-5227
Provider Business Mailing Address Fax Number:
803-773-5227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 FOREST DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-256-1511
Provider Business Practice Location Address Fax Number:
803-256-7333
Provider Enumeration Date:
02/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WHALEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
GLENN
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
803-773-5227

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP 3564 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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