Healthcare Provider Details

I. General information

NPI: 1275566440
Provider Name (Legal Business Name): BLACK RIVER HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 EAST MARKET STREET
TIMMONSVILLE SC
29161
US

IV. Provider business mailing address

PO BOX 578
MANNING SC
29102-0578
US

V. Phone/Fax

Practice location:
  • Phone: 803-433-1216
  • Fax:
Mailing address:
  • Phone: 803-433-1216
  • Fax: 803-433-6796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number79153
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16299
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27146
License Number StateSC

VIII. Authorized Official

Name: MRS. BARBARA F. BROOKS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 803-433-1216