Basic Information
| Provider Information | |||||||||
| NPI: | 1184783284 | ||||||||
| 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: | 8436631013 | ||||||||
| FaxNumber: | 8436631017 | ||||||||
| Practice Location | |||||||||
| Address1: | 7724 N KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295723041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438393939 | ||||||||
| FaxNumber: | 8438393946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | CRISWELL | ||||||||
| AuthorizedOfficialFirstName: | AVANGELA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8436631013 | ||||||||
| 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 | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 122300000X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1041C0700X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LF0000X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FQC065 | 05 | SC | MEDICAID | ZA9656 | 05 | SC | MEDICAID |