Provider Demographics
NPI:1558690305
Name:FAMILY LIFE MEDICINE
Entity Type:Organization
Organization Name:FAMILY LIFE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LORIS PHYSICIANS CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-880-6406
Mailing Address - Street 1:7209 HWY 90
Mailing Address - Street 2:SUITE C
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568
Mailing Address - Country:US
Mailing Address - Phone:843-390-1800
Mailing Address - Fax:843-390-1817
Practice Address - Street 1:7209 HWY 90
Practice Address - Street 2:SUITE C
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568
Practice Address - Country:US
Practice Address - Phone:843-390-1800
Practice Address - Fax:843-390-1817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LORIS COMMUNITY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL32240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty