Healthcare Provider Details

I. General information

NPI: 1740504869
Provider Name (Legal Business Name): RIDGILL LONG MIMS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 COMMERECE DR.
DILLON SC
29536
US

IV. Provider business mailing address

P.O. BOX 918
BENNETTSVILLE SC
29512
US

V. Phone/Fax

Practice location:
  • Phone: 843-774-3351
  • Fax:
Mailing address:
  • Phone: 843-544-4098
  • Fax: 843-454-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number207106
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: