Provider Demographics
NPI:1487644316
Name:WACCAMAW MEDICAL TRANSPORT, INC.
Entity Type:Organization
Organization Name:WACCAMAW MEDICAL TRANSPORT, INC.
Other - Org Name:LIFESTAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DEDIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-997-1535
Mailing Address - Street 1:3926 WESLEY ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-7332
Mailing Address - Country:US
Mailing Address - Phone:843-903-5290
Mailing Address - Fax:843-903-4980
Practice Address - Street 1:3926 WESLEY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7332
Practice Address - Country:US
Practice Address - Phone:843-903-5290
Practice Address - Fax:843-903-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109341600000X
NC1616341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAB0206Medicaid
SCAB0206Medicaid