Provider Demographics
NPI:1508302308
Name:COLONIAL FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:COLONIAL FAMILY PRACTICE, LLC
Other - Org Name:PRIMARY CARE AT SANTEE COOPER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-433-7444
Mailing Address - Street 1:1013 PROFESSIONAL CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2827
Mailing Address - Country:US
Mailing Address - Phone:803-433-7444
Mailing Address - Fax:803-418-0202
Practice Address - Street 1:1013 PROFESSIONAL CT
Practice Address - Street 2:SUITE C
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2827
Practice Address - Country:US
Practice Address - Phone:803-433-7444
Practice Address - Fax:803-418-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty