Healthcare Provider Details

I. General information

NPI: 1114322336
Provider Name (Legal Business Name): SUNGATE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WILLIAM POPE DR
BLUFFTON SC
29909-7549
US

IV. Provider business mailing address

10 WILLIAM POPE DR
BLUFFTON SC
29909-7549
US

V. Phone/Fax

Practice location:
  • Phone: 843-842-2020
  • Fax: 843-705-1512
Mailing address:
  • Phone: 843-842-2020
  • Fax: 843-705-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH DANIEL FARR
Title or Position: SOLE MEMBER
Credential: MD
Phone: 843-842-2020