Healthcare Provider Details

I. General information

NPI: 1841428125
Provider Name (Legal Business Name): LORIS PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

3655 MITCHELL STREET BOX 690001
LORIS SC
29569-9601
US

IV. Provider business mailing address

3655 MITCHELL STREET BOX 690001
LORIS SC
29569-9601
US

V. Phone/Fax

Practice location:
  • Phone: 843-716-7194
  • Fax: 843-716-7195
Mailing address:
  • Phone: 843-716-7194
  • Fax: 843-716-7195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TIM BROWNE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 843-716-7194