Healthcare Provider Details

I. General information

NPI: 1770908261
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 FOREST DR SUITE 101
COLUMBIA SC
29206
US

IV. Provider business mailing address

325 BROAD ST STE 100
SUMTER SC
29150-4167
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-1511
  • Fax: 803-256-7333
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-773-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateSC

VIII. Authorized Official

Name: DAVID GLENN WHALEY
Title or Position: PARTNER
Credential: MD
Phone: 803-773-5227