Provider Demographics
NPI:1912065327
Name:SPRINGDALE FAMILY PRACTICE
Entity Type:Organization
Organization Name:SPRINGDALE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:803-796-1521
Mailing Address - Street 1:3316 PLATT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2247
Mailing Address - Country:US
Mailing Address - Phone:803-796-1522
Mailing Address - Fax:803-794-7061
Practice Address - Street 1:3316 PLATT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-2247
Practice Address - Country:US
Practice Address - Phone:803-796-1522
Practice Address - Fax:803-794-7061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC9312261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPO325Medicaid
SCGPO325Medicaid
SCD90752Medicare UPIN