1396069613 NPI number — LITTLE RIVER MEDICAL CENTER, INC.

Table of content: (NPI 1396069613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396069613 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:
1396069613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
287 HIGHWAY 90 E STE 5
Provider Second Line Business Mailing Address:
STE #5
Provider Business Mailing Address City Name:
LITTLE RIVER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29566-7214
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:
9711 SAINT JAMES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29588-7431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-650-8220
Provider Business Practice Location Address Fax Number:
843-650-7909
Provider Enumeration Date:
03/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CRISWELL
Authorized Official First Name:
AVANGELA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
BUSINESS OFFICE DIRECTOR
Authorized Official Telephone Number:
84736631013

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  4406 , 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)

  • Identifier: ZA9656 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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