Basic Information
| Provider Information | |||||||||
| NPI: | 1588689020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEXINGTON MEDICAL CENTER IRMO ASC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896239 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033586160 | ||||||||
| FaxNumber: | 8034074101 | ||||||||
| Practice Location | |||||||||
| Address1: | 7035 SAINT ANDREWS RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033586160 | ||||||||
| FaxNumber: | 8034074101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | SARVIS | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8037912000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 410120 | 05 | SC | MEDICAID |