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General NPI Number Information
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NPI Number | 1558308965
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Entity Type | Organization
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Legal Business Name | BLACK RIVER HEALTHCARE, INC.
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Dates
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Enumeration Date | 06/02/2006
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Last Update Date | 04/08/2008
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Provider Practice Location Address
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Address Line | 86 N MAIN ST
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City | GREELEYVILLE
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State | SC
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Zip | 29056-9374
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Country | US
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Telephone | 843-426-2180
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Fax | 843-426-2182
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Provider Business Mailing Address
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Address Line | PO BOX 578
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City | MANNING
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State | SC
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Zip | 29102-0578
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Country | US
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Telephone | 803-433-1216
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Fax | 803-433-6796
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | LESLIE FREEMAN
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Credential |
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Telephone | 803-433-1216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 985
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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