Basic Information
| Provider Information | |||||||||
| NPI: | 1861432601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO, FAAFP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421718 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294424203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4320 HOLMESTOWN RD | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295887837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528440 | ||||||||
| FaxNumber: | 7074233501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 03/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 951 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 951 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100500484 | 05 | NV | MEDICAID | 951 | 01 | NE | NEVADA LICENSE | OTHER | CS10822 | 01 | NV | PHARMACY LICENSE | OTHER | FL3172018 | 01 | DEA NUMBER | OTHER |