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

Table of content: (NPI 1407250566)

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)





Copyright © 2007-2025 www.npivalidator.com