Basic Information
| Provider Information | |||||||||
| NPI: | 1285869222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVE OAK MEDICAL CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 342 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295563235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436870435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 342 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTREE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295563235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436870435 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 06/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | MIMS | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | DURANT | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8436870435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIVE OAK MEDICAL CENTER, PA | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 9352 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.