Healthcare Provider Details

I. General information

NPI: 1528044468
Provider Name (Legal Business Name): LAKESIDE ORTHOPAEDIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST SUITE 6
MANNING SC
29102-3149
US

IV. Provider business mailing address

50 E HOSPITAL ST SUITE 6
MANNING SC
29102-3149
US

V. Phone/Fax

Practice location:
  • Phone: 803-433-5633
  • Fax: 803-433-5636
Mailing address:
  • Phone: 803-433-5633
  • Fax: 803-433-5636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number27593
License Number StateSC

VIII. Authorized Official

Name: DAVID WOODBURY
Title or Position: OWNER
Credential: MD
Phone: 803-433-5633