Healthcare Provider Details

I. General information

NPI: 1396969002
Provider Name (Legal Business Name): LAKE CITY FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N. MATTHEWS RD.
LAKE CITY SC
29560
US

IV. Provider business mailing address

901 N. MATTHEWS RD.
LAKE CITY SC
29560
US

V. Phone/Fax

Practice location:
  • Phone: 843-374-8380
  • Fax:
Mailing address:
  • Phone: 843-374-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number17100
License Number StateSC

VIII. Authorized Official

Name: DR. MORRIS EDWARD BROWN III
Title or Position: OWNER
Credential: MD
Phone: 843-374-8380