Basic Information
| Provider Information | |||||||||
| NPI: | 1245596519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEOWEE FAMILY UROLOGY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KEOWEE FAMILY UROLOGY DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601082 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648857989 | ||||||||
| FaxNumber: | 8648857867 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 OMNI DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296729448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648857475 | ||||||||
| FaxNumber: | 8648857476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCCAIN | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8648857673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OCONEE PHYSICIAN PRACTICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.