Healthcare Provider Details

I. General information

NPI: 1336725209
Provider Name (Legal Business Name): COLONIAL FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10441 GARNERS FERRY RD
EASTOVER SC
29044-9351
US

IV. Provider business mailing address

674 W LIBERTY ST
SUMTER SC
29150-4882
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax:
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-757-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANIE KNIGHT DISHER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 803-773-5227