Provider Demographics
NPI:1275566440
Name:BLACK RIVER HEALTHCARE, INC.
Entity Type:Organization
Organization Name:BLACK RIVER HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-433-1216
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-0578
Mailing Address - Country:US
Mailing Address - Phone:803-433-1216
Mailing Address - Fax:803-433-6796
Practice Address - Street 1:206 EAST MARKET STREET
Practice Address - Street 2:
Practice Address - City:TIMMONSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29161
Practice Address - Country:US
Practice Address - Phone:803-433-1216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK RIVER HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-09
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC79153163W00000X
SC27146207Q00000X
SC16299208000000X
208D00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5009OtherMEDICARE PART B
SC5009OtherMEDICARE PART B