Healthcare Provider Details

I. General information

NPI: 1366429987
Provider Name (Legal Business Name): LOVELACE FAMILY MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WHEELER AVE
PROSPERITY SC
29127
US

IV. Provider business mailing address

PO BOX 630
PROSPERITY SC
29127-0630
US

V. Phone/Fax

Practice location:
  • Phone: 803-364-4852
  • Fax: 803-364-2014
Mailing address:
  • Phone: 803-364-4852
  • Fax: 803-364-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateSC

VIII. Authorized Official

Name: LINDA M KINARD
Title or Position: PRACTICE MANAGER
Credential:
Phone: 803-364-1011