Provider Demographics
NPI:1336699917
Name:LOW COUNTRY MALE LLC
Entity Type:Organization
Organization Name:LOW COUNTRY MALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:TWILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-936-6451
Mailing Address - Street 1:615 JOHNNIE DODDS BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3082
Mailing Address - Country:US
Mailing Address - Phone:843-936-6451
Mailing Address - Fax:843-936-6452
Practice Address - Street 1:615 JOHNNIE DODDS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3082
Practice Address - Country:US
Practice Address - Phone:843-936-6451
Practice Address - Fax:843-936-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC133152083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty