Healthcare Provider Details

I. General information

NPI: 1336424167
Provider Name (Legal Business Name): LAKE WYLIE HEALTH INVESTORS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 LATITUDE LN STE 109
LAKE WYLIE SC
29710-8117
US

IV. Provider business mailing address

PO BOX 5343
LAKE WYLIE SC
29710-5004
US

V. Phone/Fax

Practice location:
  • Phone: 803-831-2044
  • Fax: 803-939-8489
Mailing address:
  • Phone: 803-831-2044
  • Fax: 803-939-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13665
License Number StateSC

VIII. Authorized Official

Name: KYLE MCHUGH
Title or Position: PRESIDENT
Credential:
Phone: 803-240-9882