Healthcare Provider Details

I. General information

NPI: 1801972542
Provider Name (Legal Business Name): LAKE CITY COMMUNITY DAY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S BLANDING ST POB 517
LAKE CITY SC
29560-3513
US

IV. Provider business mailing address

PO BOX 517 411 S BLANDING ST
LAKE CITY SC
29560
US

V. Phone/Fax

Practice location:
  • Phone: 184-337-4808
  • Fax: 784-337-4538
Mailing address:
  • Phone: 843-374-8088
  • Fax: 843-374-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberSDC-252
License Number StateSC

VIII. Authorized Official

Name: MRS. EARLINE JAMES
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 843-374-8088