Healthcare Provider Details

I. General information

NPI: 1932423357
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 HIGHWAY 134
CONWAY SC
29527-5213
US

IV. Provider business mailing address

287 HIGHWAY 90 E STE 5 STE#5
LITTLE RIVER SC
29566-7214
US

V. Phone/Fax

Practice location:
  • Phone: 843-397-2579
  • Fax: 843-397-1426
Mailing address:
  • Phone: 843-663-1013
  • Fax: 843-663-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4406
License Number StateSC

VIII. Authorized Official

Name: MRS. AVANGELA K CRISWELL
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 843-663-1013