Provider Demographics
NPI:1427408855
Name:HOLLIS, SAMANTHA LAKE (DO)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAKE
Last Name:HOLLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANN
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:764 SACO LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3880
Mailing Address - Country:US
Mailing Address - Phone:864-855-5525
Mailing Address - Fax:
Practice Address - Street 1:764 SACO LOWELL RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3880
Practice Address - Country:US
Practice Address - Phone:864-855-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty