Provider Demographics
NPI:1407250566
Name:FOUR HOLES INDIAN ORGANIZATION EDISTO TRIBAL INC.
Entity Type:Organization
Organization Name:FOUR HOLES INDIAN ORGANIZATION EDISTO TRIBAL INC.
Other - Org Name:EDISTO INDIAN FREE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:DONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CREEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-2126
Mailing Address - Street 1:1125 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472-7846
Mailing Address - Country:US
Mailing Address - Phone:843-871-2126
Mailing Address - Fax:843-832-6019
Practice Address - Street 1:1125 RIDGE RD
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472-7846
Practice Address - Country:US
Practice Address - Phone:843-871-2126
Practice Address - Fax:843-832-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center