MEDICARE: LITTLE RIVER MEDICAL CENTER, 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	122300000X	Dentist

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	:	1619158938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE RIVER MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	287 HIGHWAY 90 E STE 5
Second Line	:	STE#5
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-7214
Country	:	US
Telephone Number	:	843-663-1017
Fax Number	:	843-663-1013

Provider Business Practice Location Address
First Line	:	5000 TULIP GROVE RD
Second Line	:
City	:	GREEN SEA
State	:	SC
Zip	:	29545-4977
Country	:	US
Telephone Number	:	843-392-1078
Fax Number	:	843-392-1090

Authorized Official
Title or Position	:	BUSINESS OFFICE DIRECTOR
Name	:	AVANGELA KAY CRISWELL
Credential	:
Telephone Number	:	843-663-1013

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	05/26/2010

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