1407250566 NPI number — FOUR HOLES INDIAN ORGANIZATION EDISTO TRIBAL INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407250566 NPI number — FOUR HOLES INDIAN ORGANIZATION EDISTO TRIBAL INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR HOLES INDIAN ORGANIZATION EDISTO TRIBAL 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:
6
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:
1407250566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29472-7846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-871-2126
Provider Business Mailing Address Fax Number:
843-832-6019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29472-7846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-871-2126
Provider Business Practice Location Address Fax Number:
843-832-6019
Provider Enumeration Date:
10/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CREEL
Authorized Official First Name:
DONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
843-871-2126

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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