Healthcare Provider Details

I. General information

NPI: 1740216191
Provider Name (Legal Business Name): LORIS MEDICAL CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 CASEY ST
LORIS SC
29569-2903
US

IV. Provider business mailing address

3439 CASEY ST
LORIS SC
29569-2903
US

V. Phone/Fax

Practice location:
  • Phone: 843-756-1582
  • Fax: 843-756-2042
Mailing address:
  • Phone: 843-756-5300
  • Fax: 843-756-6059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. WANDA GRAHAM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 843-756-5300