Provider Demographics
NPI:1316477060
Name:LAKE CITY MEDICAL ASSOCIATES 2017, LLC
Entity type:Organization
Organization Name:LAKE CITY MEDICAL ASSOCIATES 2017, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-374-3277
Mailing Address - Street 1:130 S ACLINE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 S ACLINE ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2633
Practice Address - Country:US
Practice Address - Phone:843-374-3277
Practice Address - Fax:843-374-3281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care