Provider Demographics
NPI:1164529491
Name:ALLENDALE COUNTY HOSPITAL BOARD
Entity Type:Organization
Organization Name:ALLENDALE COUNTY HOSPITAL BOARD
Other - Org Name:LAFFITTE AND WARREN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-632-3311
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-0218
Mailing Address - Country:US
Mailing Address - Phone:803-632-3311
Mailing Address - Fax:803-632-3415
Practice Address - Street 1:623 MEMORIAL AVE N
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:SC
Practice Address - Zip Code:29810-2715
Practice Address - Country:US
Practice Address - Phone:803-632-3311
Practice Address - Fax:803-632-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-041207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20044797OtherSELECT HEALTH
SC7962704OtherAETNA
SCGP3474Medicaid
SC7962704OtherAETNA
SCGP3474Medicaid
SC=========004OtherBCBS