Basic Information
| Provider Information | |||||||||
| NPI: | 1003831645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TWELVE MILE CREEK FAMILY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4711 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290729151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033563609 | ||||||||
| FaxNumber: | 8033563941 | ||||||||
| Practice Location | |||||||||
| Address1: | 4711 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290729151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033563609 | ||||||||
| FaxNumber: | 8033563941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 02/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8033563609 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.