Healthcare Provider Details

I. General information

NPI: 1730280561
Provider Name (Legal Business Name): ALLENDALE COUNTY HOSPITAL BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 ALLENDALE FAIRFAX HWY
FAIRFAX SC
29827-9133
US

IV. Provider business mailing address

PO BOX 218
FAIRFAX SC
29827-0218
US

V. Phone/Fax

Practice location:
  • Phone: 803-632-3311
  • Fax: 803-632-3415
Mailing address:
  • Phone: 803-632-3311
  • Fax: 803-632-3415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberHTL-041
License Number StateSC

VIII. Authorized Official

Name: MR. KEN HIATT
Title or Position: ADMINISTRATOR
Credential:
Phone: 803-632-3311