MEDICARE: CAROLINA RURAL PRACTICE MANAGEMENT, 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	261QR1300X	Rural Health Clinic/Center	08504	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	:	1811020183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA RURAL PRACTICE MANAGEMENT, INC.

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:	120 LOUIE ST
City	:	WAGENER
State	:	SC
Zip	:	29164-0098
Country	:	US
Telephone Number	:	803-564-6497
Fax Number	:	803-564-6498

Provider Business Practice Location Address
First Line	:	120 LOUIE STREET
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164-0098
Country	:	US
Telephone Number	:	803-564-6497
Fax Number	:	803-564-6498

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. CHARLIE CLIFTON ALSBROOKS
Credential	:
Telephone Number	:	803-641-6277

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/12/2007

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