Provider Demographics
NPI:1174257067
Name:COLONIAL FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:KNIGHT
Authorized Official - Last Name:DISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-773-5227
Mailing Address - Street 1:674 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4882
Mailing Address - Country:US
Mailing Address - Phone:803-773-5227
Mailing Address - Fax:803-757-4010
Practice Address - Street 1:325 BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4167
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-418-0202
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLONIAL FAMILY PRACTICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty