Organization
COFA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KELVIN WILLIAMS (EXECUTIVE DIRECTOR)
(843) 229-8504
Entity
Organization
Contact information
Practice address
106 E THOMAS ST, LAKE CITY, SC 29560-2639
(843) 229-8504
(843) 374-2632
Mailing address
106 EAST THOMAS STREET, PO BOX 394, LAKE CITY, SC 29560
(866) 285-0122
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
55
SC
2084P0800X
Psychiatry Physician
Primary
213469
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GP3880
—
SC
05
—
GP4013
—
SC
Enumeration date
05/11/2007
Last updated
01/17/2008
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