Healthcare Provider Details

I. General information

NPI: 1548296098
Provider Name (Legal Business Name): PEE DEEDIABETIC CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W MAIN ST
LAKE CITY SC
29560-2428
US

IV. Provider business mailing address

212 ACADEMY ST
LAKE CITY SC
29560-2102
US

V. Phone/Fax

Practice location:
  • Phone: 843-394-3121
  • Fax:
Mailing address:
  • Phone: 843-394-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCDE 136743
License Number StateSC

VIII. Authorized Official

Name: JANE DIXON PLAYER
Title or Position: ADMINISTRATOR/OWNER
Credential: RPH,CDE
Phone: 843-394-3121