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General NPI Number Information
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NPI Number | 1912964479
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Entity Type | Organization
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Legal Business Name | LAKE MARION PRIMARY CARE
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Dates
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Enumeration Date | 04/27/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 15 E HOSPITAL ST
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City | MANNING
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State | SC
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Zip | 29102-3152
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Country | US
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Telephone | 803-435-2529
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Fax | 803-435-4196
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Provider Business Mailing Address
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Address Line | 15 E HOSPITAL ST
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City | MANNING
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State | SC
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Zip | 29102-3152
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Country | US
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Telephone | 803-435-2529
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Fax | 803-435-4196
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SAUNDRA WALLACE
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Credential |
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Telephone | 803-435-2529
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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 | 13275
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 20345
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License Number State | SC
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