Healthcare Provider Details

I. General information

NPI: 1912654989
Provider Name (Legal Business Name): BLACK RIVER MEDICAL SUPPLIES AND EQUIPMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 NELSON BLVD
KINGSTREE SC
29556-4025
US

IV. Provider business mailing address

482 NELSON BLVD
KINGSTREE SC
29556-4025
US

V. Phone/Fax

Practice location:
  • Phone: 843-355-5545
  • Fax: 843-355-5546
Mailing address:
  • Phone: 843-355-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: VICKIE B MITCHELL
Title or Position: CO-OWNER
Credential: BA
Phone: 843-355-5545