Healthcare Provider Details

I. General information

NPI: 1184783284
Provider Name (Legal Business Name): LITTLE RIVER MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7724 N KINGS HWY
MYRTLE BEACH SC
29572-3041
US

IV. Provider business mailing address

PO BOX 547
LITTLE RIVER SC
29566-0547
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-3939
  • Fax: 843-839-3946
Mailing address:
  • Phone: 843-663-1013
  • Fax: 843-663-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateSC

VIII. Authorized Official

Name: MRS. AVANGELA KAY CRISWELL
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 843-663-1013