Healthcare Provider Details

I. General information

NPI: 1629021076
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/21/2014
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: 843-280-2455
Mailing address:
  • Phone: 843-663-8000
  • Fax: 843-663-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateSC
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: PAMELA R DAVIS
Title or Position: CEO
Credential:
Phone: 843-663-8001