Healthcare Provider Details

I. General information

NPI: 1780643049
Provider Name (Legal Business Name): LB & KM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 HWY 17 BYPASS
MURRELLS INLET SC
29576-5016
US

IV. Provider business mailing address

PO BOX 2747
MURRELLS INLET SC
29576-2662
US

V. Phone/Fax

Practice location:
  • Phone: 843-357-1299
  • Fax: 843-357-2264
Mailing address:
  • Phone: 843-357-1299
  • Fax: 843-357-2264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO 411
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD17689
License Number StateSC

VIII. Authorized Official

Name: DR. GAYLE L BROOK
Title or Position: PARTNER
Credential: D.O
Phone: 843-357-1299