Basic Information
| Provider Information | |||||||||
| NPI: | 1932113230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY DIAGNOSTICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 922 HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290592762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034967174 | ||||||||
| FaxNumber: | 8034967928 | ||||||||
| Practice Location | |||||||||
| Address1: | 922 HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290592762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034967174 | ||||||||
| FaxNumber: | 8034967928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 02/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | WAY | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8034967174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY DIAGNOSTIC ASSOC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | RHC011 | 05 | SC | MEDICAID | L00039 | 05 | SC | MEDICAID |