Basic Information
| Provider Information | |||||||||
| NPI: | 1780643049 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LB & KM LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE DOC HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2747 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433571299 | ||||||||
| FaxNumber: | 8433572264 | ||||||||
| Practice Location | |||||||||
| Address1: | 4630 HWY 17 BYPASS | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295765016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433571299 | ||||||||
| FaxNumber: | 8433572264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROOK | ||||||||
| AuthorizedOfficialFirstName: | GAYLE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8433571299 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD17689 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207Q00000X | DO 411 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP3579 | 05 | SC | MEDICAID | CK3853 | 01 | SC | RAILROAD MEDICARE | OTHER |