Basic Information
Provider Information | |||||||||
NPI: | 1700378767 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DENMARK-OLAR MIDDLE SCHOOL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3310 MAGNOLIA ST | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291151466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035316900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 45 GREEN ST | ||||||||
Address2: |   | ||||||||
City: | DENMARK | ||||||||
State: | SC | ||||||||
PostalCode: | 29042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037933383 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2018 | ||||||||
LastUpdateDate: | 06/05/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUNSON | ||||||||
AuthorizedOfficialFirstName: | LEON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8035316900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FAMILY HEALTH CENTERS, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | SR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.