Basic Information
| Provider Information | |||||||||
| NPI: | 1275861536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WACCAMAW COMMUNITY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 DICK POND RD | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295886807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528100 | ||||||||
| FaxNumber: | 8436528122 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 DICK POND RD | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295886807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528100 | ||||||||
| FaxNumber: | 8436528122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | GASKINS | ||||||||
| AuthorizedOfficialFirstName: | BROOKE | ||||||||
| AuthorizedOfficialMiddleName: | COX | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR;GEORGETOWN PHYSICIAN SERVI | ||||||||
| AuthorizedOfficialTelephone: | 8435208441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.