Healthcare Provider Details

I. General information

NPI: 1558690305
Provider Name (Legal Business Name): FAMILY LIFE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7209 HWY 90 SUITE C
LONGS SC
29568
US

IV. Provider business mailing address

7209 HWY 90 SUITE C
LONGS SC
29568
US

V. Phone/Fax

Practice location:
  • Phone: 843-390-1800
  • Fax: 843-390-1817
Mailing address:
  • Phone: 843-390-1800
  • Fax: 843-390-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL32240
License Number StateSC

VIII. Authorized Official

Name: MRS. CAROLYN WARD
Title or Position: LORIS PHYSICIANS CREDENTIALING
Credential:
Phone: 919-880-6406