Healthcare Provider Details

I. General information

NPI: 1619100096
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3817 MAIN ST
LORIS SC
29569-3017
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: 843-756-6828
Mailing address:
  • Phone: 843-663-8000
  • Fax: 843-663-1018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateSC

VIII. Authorized Official

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