Provider Demographics
NPI:1366429987
Name:LOVELACE FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:LOVELACE FAMILY MEDICINE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KINARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-364-1011
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-0630
Mailing Address - Country:US
Mailing Address - Phone:803-364-4852
Mailing Address - Fax:803-364-2014
Practice Address - Street 1:600 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127
Practice Address - Country:US
Practice Address - Phone:803-364-4852
Practice Address - Fax:803-364-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QP2300X, 291U00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3757Medicaid
SC0739330001OtherDME/MEDICARE
SCDM0459OtherDME/MEDICAID
SCGP0018Medicaid
SCGP3757Medicaid