Basic Information
Provider Information | |||||||||
NPI: | 1306922646 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LORIS COMMUNITY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LORIS FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3655 MITCHELL ST | ||||||||
Address2: | BOX 690001 | ||||||||
City: | LORIS | ||||||||
State: | SC | ||||||||
PostalCode: | 295699601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437167270 | ||||||||
FaxNumber: | 8437569260 | ||||||||
Practice Location | |||||||||
Address1: | 3204 CASEY ST | ||||||||
Address2: |   | ||||||||
City: | LORIS | ||||||||
State: | SC | ||||||||
PostalCode: | 29569 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437167270 | ||||||||
FaxNumber: | 8437569260 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2006 | ||||||||
LastUpdateDate: | 01/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TODD | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/CFO | ||||||||
AuthorizedOfficialTelephone: | 8437167520 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | HTL033 | SC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | RHC041 | 05 | SC |   | MEDICAID |