Provider Demographics
NPI:1225304546
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:
Authorized Official - First Name:AVANGELA
Authorized Official - Middle Name:K
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:843-663-8000
Mailing Address - Fax:843-663-1017
Practice Address - Street 1:1411 10TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5615
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:843-663-1017
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE RIVER MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3657101YP2500X
SC7136104100000X
SC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty