Provider Demographics
NPI:1427015536
Name:MID-CAROLINA MEDICAL LLC
Entity Type:Organization
Organization Name:MID-CAROLINA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANK
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-408-2858
Mailing Address - Street 1:2465 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8833
Mailing Address - Country:US
Mailing Address - Phone:803-408-2858
Mailing Address - Fax:803-408-2874
Practice Address - Street 1:2465 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8833
Practice Address - Country:US
Practice Address - Phone:803-408-2858
Practice Address - Fax:803-408-2874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2710Medicaid
SCDE2710Medicaid