Provider Demographics
NPI:1336684851
Name:NORTHLAKE FAMILY PRACTICE
Entity Type:Organization
Organization Name:NORTHLAKE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-622-3559
Mailing Address - Street 1:115 BLARNEY DR
Mailing Address - Street 2:SUITE 101 C
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6291
Mailing Address - Country:US
Mailing Address - Phone:803-419-5131
Mailing Address - Fax:
Practice Address - Street 1:115 BLARNEY DR
Practice Address - Street 2:SUITE 101 C
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6291
Practice Address - Country:US
Practice Address - Phone:803-419-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization