Provider Demographics
NPI:1760633960
Name:THE MEDICAL PLACE FAMILY PRACTICE, P.A.
Entity Type:Organization
Organization Name:THE MEDICAL PLACE FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:MATTHEWS
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-358-9843
Mailing Address - Street 1:212 CHERRY GROVE DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-3070
Mailing Address - Country:US
Mailing Address - Phone:803-358-9843
Mailing Address - Fax:803-358-9843
Practice Address - Street 1:3020 SUNSET BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3493
Practice Address - Country:US
Practice Address - Phone:803-791-5680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24923261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care