Provider Demographics
NPI:1235573015
Name:LAKE MURRAY PAIN AND REHAB, LLC
Entity Type:Organization
Organization Name:LAKE MURRAY PAIN AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BULL
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:803-345-0334
Mailing Address - Street 1:510 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-9424
Mailing Address - Country:US
Mailing Address - Phone:803-345-0334
Mailing Address - Fax:803-345-0335
Practice Address - Street 1:510 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-9424
Practice Address - Country:US
Practice Address - Phone:803-345-0334
Practice Address - Fax:803-345-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC111N00000X111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty