Healthcare Provider Details

I. General information

NPI: 1952350142
Provider Name (Legal Business Name): EDISTO REGIONAL HEALTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 BUNCH FORD ROAD
HOLLY HILL SC
29059
US

IV. Provider business mailing address

PO BOX 188
HOLLY HILL SC
29059-0188
US

V. Phone/Fax

Practice location:
  • Phone: 803-496-3312
  • Fax:
Mailing address:
  • Phone: 803-395-4480
  • Fax: 803-395-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA M GOODLETT
Title or Position: C.O.O
Credential:
Phone: 803-395-2462