Healthcare Provider Details

I. General information

NPI: 1073888400
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

PO BOX 547
LITTLE RIVER SC
29566-0547
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-4888
  • Fax: 843-663-1017
Mailing address:
  • Phone: 843-663-8000
  • Fax: 843-663-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3657
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7136
License Number StateSC

VIII. Authorized Official

Name: MRS. AVANGELA K CRISWELL
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 843-663-8017