Healthcare Provider Details

I. General information

NPI: 1497104525
Provider Name (Legal Business Name): MCLEOD HEALTH CLARENDON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BOZARD ST
MANNING SC
29102-2935
US

IV. Provider business mailing address

22 BOZARD ST
MANNING SC
29102-2935
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-8828
  • Fax:
Mailing address:
  • Phone: 803-435-8828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL FULTON ERVIN III
Title or Position: SR VICE PRESIDENT AND CFO
Credential:
Phone: 843-777-2910