=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215420195
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE BRAYE MD, MPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2018
-----------------------------------------------------
Last Update Date | 08/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 MAIN ST STE A
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-229-4446
-----------------------------------------------------
Fax | 864-229-8037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 MAIN ST STE A
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-229-4446
-----------------------------------------------------
Fax | 864-229-8037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 276102
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 88589
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------