Healthcare Provider Details

I. General information

NPI: 1053471623
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 LIVE OAK DR
LITTLE RIVER SC
29566-9138
US

IV. Provider business mailing address

PO BOX 547
LITTLE RIVER SC
29566-0547
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-8000
  • Fax: 843-663-8154
Mailing address:
  • Phone: 843-663-8017
  • Fax: 843-663-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4406
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. AVANGELA KAY CRISWELL
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 843-663-8017