Provider Demographics
NPI:1053471623
Name:LITTLE RIVER MEDICAL CENTER INC
Entity Type:Organization
Organization Name:LITTLE RIVER MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVANGELA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CRISWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-663-8017
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8017
Mailing Address - Fax:843-663-1017
Practice Address - Street 1:4303 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9138
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:843-663-8154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE RIVER MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-12
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4406122300000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9656Medicaid