| Lake Monticello Family Practice @mccrorey Liston | |
|
1978 State Highway 215 S Blair SC 29015-9443 | |
| (803) 402-6782 | |
| (803) 635-6628 |
| Full Name | Lake Monticello Family Practice @mccrorey Liston |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 1978 State Highway 215 S, Blair, South Carolina |
| Authorized Official Name and Position | Delgado Cantave (CEO) |
| Authorized Official Contact | 8037335969 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Monticello Family Practice @mccrorey Liston Po Box 3788 Columbia SC 29230-3788 Ph: (803) 733-5969 | Lake Monticello Family Practice @mccrorey Liston 1978 State Highway 215 S Blair SC 29015-9443 Ph: (803) 402-6782 |
| NPI Number | 1841689288 |
|---|---|
| Provider Enumeration Date | 01/22/2015 |
| Last Update Date | 02/10/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841689288 | NPI | - | NPPES |
| CBP018 | Medicaid | SC | |
| FQC031 | Medicaid | SC | |
| FQC180 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |