Basic Information
Provider Information | |||||||||
NPI: | 1386967818 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LITTLE RIVER MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 287 HIGHWAY 90 E STE 5 | ||||||||
Address2: |   | ||||||||
City: | LITTLE RIVER | ||||||||
State: | SC | ||||||||
PostalCode: | 295667214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436631013 | ||||||||
FaxNumber: | 8436631017 | ||||||||
Practice Location | |||||||||
Address1: | 6612 29TH AVE NORTH | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295773169 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8436631013 | ||||||||
FaxNumber: | 8434480139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2010 | ||||||||
LastUpdateDate: | 03/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRISWELL | ||||||||
AuthorizedOfficialFirstName: | AVANGELA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8436631013 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LITTLE RIVER MEDICAL CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 4406 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | ZA9656 | 05 | SC |   | MEDICAID |