| Prime Care Of The Lower Pee Dee, Llc | |
|
263 Kelley St Ste 100 Lake City SC 29560-2472 | |
| (843) 394-8274 | |
| (843) 394-1604 |
| Full Name | Prime Care Of The Lower Pee Dee, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 263 Kelley St Ste 100, Lake City, South Carolina |
| Authorized Official Name and Position | Tyrone Delmar Wallace (OWNER) |
| Authorized Official Contact | 8433948274 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Prime Care Of The Lower Pee Dee, Llc 263 Kelleyst Ste 100 Lake City SC 29560 Ph: (843) 394-8274 | Prime Care Of The Lower Pee Dee, Llc 263 Kelley St Ste 100 Lake City SC 29560-2472 Ph: (843) 394-8274 |
| NPI Number | 1437692407 |
|---|---|
| Provider Enumeration Date | 11/23/2016 |
| Last Update Date | 11/23/2016 |
| Medicare PECOS PAC ID | 0749563120 |
|---|---|
| Medicare Enrollment ID | O20170208002843 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437692407 | NPI | - | NPPES |
| CH1873 | Medicaid | SC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | SC 1873 (South Carolina) | Primary |
| Provider Name | Lafayette Briggs |
|---|---|
| Provider Type | Practitioner - Chiropractic |
| Provider Identifiers | NPI Number: 1881796332 PECOS PAC ID: 7810940582 Enrollment ID: I20050223000356 |
| Provider Name | Tyrone D Wallace |
|---|---|
| Provider Type | Practitioner - Chiropractic |
| Provider Identifiers | NPI Number: 1780633420 PECOS PAC ID: 1557541224 Enrollment ID: I20110404000657 |
| Provider Name | Chucky Sentell Jordan |
|---|---|
| Provider Type | Practitioner - Chiropractic |
| Provider Identifiers | NPI Number: 1841656527 PECOS PAC ID: 4688971658 Enrollment ID: I20160318001683 |
| Provider Name | Sarah Jewell |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1174982250 PECOS PAC ID: 4981993896 Enrollment ID: I20160517000824 |
| Provider Name | Angel Thompson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1881057602 PECOS PAC ID: 7911287115 Enrollment ID: I20161205002024 |
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