Provider Demographics
NPI:1295834992
Name:ALLENDALE COUNTY HOSPITAL BOARD
Entity Type:Organization
Organization Name:ALLENDALE COUNTY HOSPITAL BOARD
Other - Org Name:ALLENDALE COUNTY HOSPITAL SWING BED
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 1:1787 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9133
Practice Address - Country:US
Practice Address - Phone:803-632-3311
Practice Address - Fax:803-632-3415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLENDALE COUNTY HOSPITAL BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-041282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0041SBMedicaid
SC=========003OtherBCBS SWING BED
SC42Z300Medicare Oscar/Certification