Provider Demographics
NPI:1083761316
Name:DUTCH FORK FAMILY PRACTICE
Entity Type:Organization
Organization Name:DUTCH FORK FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-732-8370
Mailing Address - Street 1:110 DUTCHMAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-732-8370
Mailing Address - Fax:803-732-8373
Practice Address - Street 1:110 DUTCHMAN BLVD.
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-732-8370
Practice Address - Fax:803-732-8373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care