Organization
PRIME CARE OF THE LOWER PEE DEE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TYRONE DELMAR WALLACE DC (OWNER)
(843) 394-8274
Entity
Organization
Contact information
Practice address
263 KELLEY ST STE 100, LAKE CITY, SC 29560-2472
(843) 394-8274
(843) 394-1604
Mailing address
263 KELLEYST STE 100, LAKE CITY, SC 29560
(843) 394-8274
(843) 394-1604
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
SC 1873
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
CH1873
—
SC
Enumeration date
11/23/2016
Last updated
11/23/2016
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