Basic Information
| Provider Information | |||||||||
| NPI: | 1053471623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LITTLE RIVER MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295660547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638017 | ||||||||
| FaxNumber: | 8436631017 | ||||||||
| Practice Location | |||||||||
| Address1: | 4303 LIVE OAK DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295669138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | 8436638154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRISWELL | ||||||||
| AuthorizedOfficialFirstName: | AVANGELA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8436638017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE RIVER MEDICAL CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 122300000X | 4406 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | ZA9656 | 05 | SC | MEDICAID |