1891985982 NPI number — WOODLANDWAY FAMILY PRACTICE

Table of content: (NPI 1891985982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891985982 NPI number — WOODLANDWAY FAMILY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODLANDWAY FAMILY PRACTICE
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:
1891985982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 98
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR PLAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29643-0098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-972-5720
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 WEST PINE GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRPLAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-972-5720
Provider Business Practice Location Address Fax Number:
864-972-5724
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BECKER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
864-972-5720

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23572 , 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: 235720 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com