Healthcare Provider Details

I. General information

NPI: 1073264008
Provider Name (Legal Business Name): MR. MAKENZIE RYAN LOBDELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHLAND MEDICAL PARK DR STE 300
COLUMBIA SC
29203-6831
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7910
  • Fax: 803-933-3022
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number29210
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number29210
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: