Provider Demographics
NPI:1790705259
Name:PENDLETON FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:PENDLETON FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-646-7522
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-0547
Mailing Address - Country:US
Mailing Address - Phone:864-646-7522
Mailing Address - Fax:864-646-3377
Practice Address - Street 1:101 SHIRLEY ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-1824
Practice Address - Country:US
Practice Address - Phone:864-646-7522
Practice Address - Fax:864-646-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3375Medicaid
SC7205Medicare ID - Type Unspecified
SC7205Medicare PIN