Provider Demographics
NPI:1407947955
Name:PHILLIP L. LATHAM JR
Entity Type:Organization
Organization Name:PHILLIP L. LATHAM JR
Other - Org Name:PHILLIP L. LATHAM JR
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-775-4469
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:325 BROAD STREET SUITE 200
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:803-775-4469
Mailing Address - Fax:803-775-4981
Practice Address - Street 1:325 BROAD STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-775-4469
Practice Address - Fax:803-775-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14449174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC144490Medicaid
SC144490Medicaid
SC6391Medicare ID - Type Unspecified