Provider Demographics
NPI:1568585966
Name:FOREST FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:FOREST FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-903-4401
Mailing Address - Street 1:3874 RENEE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579
Mailing Address - Country:US
Mailing Address - Phone:843-903-4401
Mailing Address - Fax:
Practice Address - Street 1:3874 RENEE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-903-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF 2018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1386699866Medicare ID - Type UnspecifiedNPI