Basic Information
Provider Information | |||||||||
NPI: | 1811922164 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LEXINGTON MEDICAL CENTER IRMO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 07/12/2006 | ||||||||
LastUpdateDate: | 09/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SARVIS | ||||||||
AuthorizedOfficialFirstName: | MELINDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VP | ||||||||
AuthorizedOfficialTelephone: | 8037912000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LEXINGTON COUNTY HEALTH SERVICES DISTRICT, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | SL0023 | 05 | SC |   | MEDICAID |