Healthcare Provider Details

I. General information

NPI: 1992077424
Provider Name (Legal Business Name): BLACK RIVER HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 W. HOSPITAL ST.
MANNING SC
29102-2925
US

IV. Provider business mailing address

PO BOX 578
MANNING SC
29102-0578
US

V. Phone/Fax

Practice location:
  • Phone: 803-433-4321
  • Fax: 803-433-0075
Mailing address:
  • Phone: 803-433-6790
  • Fax: 803-433-6796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BARBARA F. BROOKS
Title or Position: C.E.O.
Credential:
Phone: 803-433-6790