1770908261 NPI number — COLONIAL FAMILY PRACTICE, LLC

Table of Contents

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

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




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