Healthcare Provider Details

I. General information

NPI: 1245596519
Provider Name (Legal Business Name): KEOWEE FAMILY UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 OMNI DR SUITE A
SENECA SC
29672-9448
US

IV. Provider business mailing address

PO BOX 601082
CHARLOTTE NC
28260-1082
US

V. Phone/Fax

Practice location:
  • Phone: 864-885-7475
  • Fax: 864-885-7476
Mailing address:
  • Phone: 864-885-7989
  • Fax: 864-885-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BRYAN M. MCCAIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 864-885-7673