Provider Demographics
NPI:1417175894
Name:WACCAMAW MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:WACCAMAW MEDICAL SERVICES, INC.
Other - Org Name:RIEGELWOOD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOYES
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:910-655-0021
Mailing Address - Street 1:210 HWY 87
Mailing Address - Street 2:
Mailing Address - City:RIEGELWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28456-0118
Mailing Address - Country:US
Mailing Address - Phone:910-655-0021
Mailing Address - Fax:910-655-2777
Practice Address - Street 1:210 HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:RIEGELWOOD
Practice Address - State:NC
Practice Address - Zip Code:28456-0118
Practice Address - Country:US
Practice Address - Phone:910-655-0021
Practice Address - Fax:910-655-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343911AMedicaid
NC89014Medicaid
NC343911CMedicaid
NC1128QOtherNC BC
NC343911CMedicaid
NC1128QOtherNC BC