Provider Demographics
NPI:1528362621
Name:LAKE MURRAY PAIN AND REHAB
Entity Type:Organization
Organization Name:LAKE MURRAY PAIN AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-345-0334
Mailing Address - Street 1:510 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-9424
Mailing Address - Country:US
Mailing Address - Phone:803-345-0334
Mailing Address - Fax:803-345-0335
Practice Address - Street 1:510 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-9424
Practice Address - Country:US
Practice Address - Phone:803-345-0334
Practice Address - Fax:803-345-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7485171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCB-918234244Medicare UPIN