Healthcare Provider Details

I. General information

NPI: 1689869018
Provider Name (Legal Business Name): MCLEOD PHYSICIAN ASSOCIATES II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108A EAST MAIN STREET
LATTA SC
29565-1617
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-752-5111
  • Fax: 843-752-5100
Mailing address:
  • Phone: 843-752-5111
  • Fax: 843-752-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL PROVENZANO
Title or Position: REGIONAL PRACTICE MANAGER/AVP
Credential:
Phone: 843-777-7030