Basic Information
| Provider Information | |||||||||
| NPI: | 1225304546 | ||||||||
| 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: | 8436638000 | ||||||||
| FaxNumber: | 8436631017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 10TH AVE N | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295775615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436638000 | ||||||||
| FaxNumber: | 8436631017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2012 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | CRISWELL | ||||||||
| AuthorizedOfficialFirstName: | AVANGELA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8436638017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LITTLE RIVER MEDICAL CENTER, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3657 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | 7136 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 207Q00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.