Healthcare Provider Details

I. General information

NPI: 1336439314
Provider Name (Legal Business Name): LCHCS DBA WILSON AND MCCORMACK SURGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MEDICAL RIDGE RD
CLINTON SC
29325-4542
US

IV. Provider business mailing address

1012 MEDICAL RIDGE RD
CLINTON SC
29325-4542
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-3852
  • Fax:
Mailing address:
  • Phone: 864-833-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33377
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33343
License Number StateSC

VIII. Authorized Official

Name: MR. WILLIS J GRANT IV
Title or Position: VP AND CFO OF LCHCS
Credential:
Phone: 864-833-3976