Provider Demographics
NPI:1659346542
Name:ADVANCED MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:678-689-2388
Mailing Address - Street 1:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29834-1860
Mailing Address - Country:US
Mailing Address - Phone:803-593-3411
Mailing Address - Fax:678-689-1459
Practice Address - Street 1:2820 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:SC
Practice Address - Zip Code:29834
Practice Address - Country:US
Practice Address - Phone:803-593-3411
Practice Address - Fax:803-593-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
SC91813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7-9181-7Medicaid
2089399OtherPK