Provider Demographics
NPI:1336516921
Name:TOWN OF WAGENER SOUTH CAROLINA
Entity Type:Organization
Organization Name:TOWN OF WAGENER SOUTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ARMAND
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-564-8803
Mailing Address - Street 1:120 LOUIE ST AND P O BOX 400
Mailing Address - Street 2:
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164
Mailing Address - Country:US
Mailing Address - Phone:803-564-8803
Mailing Address - Fax:803-564-8804
Practice Address - Street 1:120 LOUIE ST
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164-9445
Practice Address - Country:US
Practice Address - Phone:803-564-8803
Practice Address - Fax:803-564-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QH0100X261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service