Basic Information
| Provider Information | |||||||||
| NPI: | 1194806604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LORIS COMMUNITY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MT OLIVE FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3655 MITCHELL ST | ||||||||
| Address2: | BOX 690001 | ||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433929222 | ||||||||
| FaxNumber: | 8433921445 | ||||||||
| Practice Location | |||||||||
| Address1: | 5260 HWY 9 | ||||||||
| Address2: | |||||||||
| City: | GREEN SEA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433929222 | ||||||||
| FaxNumber: | 8433921445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | TODD | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437167520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC502 | 05 | SC | MEDICAID |