Healthcare Provider Details

I. General information

NPI: 1588941520
Provider Name (Legal Business Name): MCLEOD LORIS SEACOAST HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 STEVENS ST
LORIS SC
29569-2953
US

IV. Provider business mailing address

PO BOX 100567
FLORENCE SC
29502-0567
US

V. Phone/Fax

Practice location:
  • Phone: 843-716-7106
  • Fax: 843-716-7026
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCF207
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SAMUEL FULTON ERVIN III
Title or Position: SR VP AND CFO
Credential:
Phone: 843-777-2910