Provider Demographics
NPI:1528066115
Name:PROVIDENCE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:PROVIDENCE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FRAMPTON
Authorized Official - Middle Name:W
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:803-254-5171
Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2038
Mailing Address - Country:US
Mailing Address - Phone:803-254-5171
Mailing Address - Fax:803-779-7403
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2023
Practice Address - Country:US
Practice Address - Phone:803-254-5171
Practice Address - Fax:803-779-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13507207Q00000X
SC21987207Q00000X
SC8387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2164Medicaid
SCCM5571OtherRAILROAD MEDICARE
SCCM5571OtherRAILROAD MEDICARE