Provider Demographics
NPI:1215106794
Name:LOWCOUNTRY CENTER FOR DIABETES & ENDOCRINOLOGY PA
Entity type:Organization
Organization Name:LOWCOUNTRY CENTER FOR DIABETES & ENDOCRINOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-538-8585
Mailing Address - Street 1:16 NORTHSIDE DR.
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488
Mailing Address - Country:US
Mailing Address - Phone:843-538-8585
Mailing Address - Fax:843-538-4777
Practice Address - Street 1:16 NORTHSIDE DR.
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488
Practice Address - Country:US
Practice Address - Phone:843-538-8585
Practice Address - Fax:843-538-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20023174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2198Medicaid
SC460002249OtherRAILROAD MEDICARE
SCGP2198Medicaid