Provider Demographics
NPI:1497178131
Name:COLONIAL FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE, LLC
Other - Org Name:COLONIAL FAMILY PRACTICE BULTMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:DISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-773-5227
Mailing Address - Street 1:325 BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4167
Mailing Address - Country:US
Mailing Address - Phone:803-773-5227
Mailing Address - Fax:803-753-9312
Practice Address - Street 1:698 BULTMAN DR
Practice Address - Street 2:SUITE A
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-753-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2020-12-15
Deactivation Date:2020-11-03
Deactivation Code:
Reactivation Date:2020-12-15
Provider Licenses
StateLicense IDTaxonomies
SC17676207Q00000X
SCSC1752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3564Medicaid
SC42D2126583OtherCLIA