Healthcare Provider Details

I. General information

NPI: 1962851097
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: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E HOSPITAL ST
MANNING SC
29102-3160
US

IV. Provider business mailing address

200 E HOSPITAL ST
MANNING SC
29102-3160
US

V. Phone/Fax

Practice location:
  • Phone: 803-433-0439
  • Fax:
Mailing address:
  • Phone: 803-433-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
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