MEDICARE: WACCAMAW MEDICAL TRANSPORT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance	1616	NC
2	341600000X	Ambulance	109	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487644316
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WACCAMAW MEDICAL TRANSPORT, INC.

Provider Business Mailing Address
First Line	:	3926 WESLEY ST
Second Line	:	SUITE 202
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-7332
Country	:	US
Telephone Number	:	843-903-5290
Fax Number	:	843-903-4980

Provider Business Practice Location Address
First Line	:	3926 WESLEY ST
Second Line	:	SUITE 202
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-7332
Country	:	US
Telephone Number	:	843-903-5290
Fax Number	:	843-903-4980

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	DEDIE J. GARREN
Credential	:
Telephone Number	:	843-997-1535

Provider Enumeration Date	:	10/22/2005
Last Update Date	:	08/22/2020

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