| Lake Monticello Family Practice | |
|
9017 State Highway 215 S Jenkinsville SC 29065-9428 | |
| (803) 298-2068 | |
| (803) 298-2069 |
| Full Name | Lake Monticello Family Practice |
|---|---|
| Speciality | Clinic/Center |
| Location | 9017 State Highway 215 S, Jenkinsville, South Carolina |
| Authorized Official Name and Position | Delgado Cantave (CEO) |
| Authorized Official Contact | 8037335969 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Monticello Family Practice Po Box 3788 Columbia SC 29230-3788 Ph: (803) 753-5591 | Lake Monticello Family Practice 9017 State Highway 215 S Jenkinsville SC 29065-9428 Ph: (803) 298-2068 |
| NPI Number | 1326267592 |
|---|---|
| Provider Enumeration Date | 04/25/2007 |
| Last Update Date | 02/03/2022 |
| Medicare PECOS PAC ID | 3274434220 |
|---|---|
| Medicare Enrollment ID | O20120622000330 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1326267592 | NPI | - | NPPES |
| FQC126 | Medicaid | SC | |
| CBP018 | Medicaid | SC | |
| FQC031 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |