Basic Information
| Provider Information | |||||||||
| NPI: | 1952924896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | W. LAFAYETTE HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAFAYETTE DPC-1 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 CENTIMETERS DR | ||||||||
| Address2: | |||||||||
| City: | MAULDIN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296623278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645010751 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2701B KENT AVE | ||||||||
| Address2: | |||||||||
| City: | W LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479061350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123088400 | ||||||||
| FaxNumber: | 7656009796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2020 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | KEMBLE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF MEDICAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 8645010815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROACTIVE MSO, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.