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General NPI Number Information
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NPI Number | 1235364282
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Entity Type | Organization
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Legal Business Name | LIVE OAK MEDICAL CENTER, PA
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Dates
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Enumeration Date | 05/20/2009
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Last Update Date | 07/09/2010
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Provider Practice Location Address
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Address Line | 342 W MAIN ST
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City | KINGSTREE
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State | SC
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Zip | 29556-3235
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Country | US
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Telephone | 843-355-3621
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Fax |
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Provider Business Mailing Address
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Address Line | 342 W MAIN ST
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City | KINGSTREE
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State | SC
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Zip | 29556-3235
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Country | US
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Telephone | 843-687-0435
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | ALBERT DURANT MIMS
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Credential | M.D.
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Telephone | 843-687-0435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 9352
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License Number State | SC
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