Healthcare Provider Details

I. General information

NPI: 1679819965
Provider Name (Legal Business Name): LISA A RUOHONIEMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A LARK

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10706 CLEMSON BLVD
SENECA SC
29678-4528
US

IV. Provider business mailing address

10706 CLEMSON BLVD
SENECA SC
29678-4528
US

V. Phone/Fax

Practice location:
  • Phone: 864-888-3020
  • Fax: 864-888-8585
Mailing address:
  • Phone: 864-888-3020
  • Fax: 864-888-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35269
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: