1669535225 NPI number — LITTLE RIVER MEDICAL CENTER, INC.

Table of content: (NPI 1669535225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669535225 NPI number — LITTLE RIVER MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE RIVER MEDICAL CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669535225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE RIVER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29566-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-663-1013
Provider Business Mailing Address Fax Number:
843-663-1017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 MR. JOE WHITE AVE
Provider Second Line Business Practice Location Address:
UNIT 101
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-5658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-839-2049
Provider Business Practice Location Address Fax Number:
843-839-1857
Provider Enumeration Date:
12/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRISWELL
Authorized Official First Name:
AVANGELA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
BUSINESS OFFICE DIRECTOR
Authorized Official Telephone Number:
843-663-1013

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FQC066 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".