Provider Demographics
NPI:1508809542
Name:BLACK RIVER HEALTHCARE, INC.
Entity Type:Organization
Organization Name:BLACK RIVER HEALTHCARE, INC.
Other - Org Name:BRH - OLANTA
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-433-1216
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-0578
Mailing Address - Country:US
Mailing Address - Phone:803-433-1216
Mailing Address - Fax:803-433-6796
Practice Address - Street 1:139 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OLANTA
Practice Address - State:SC
Practice Address - Zip Code:29114
Practice Address - Country:US
Practice Address - Phone:803-433-1216
Practice Address - Fax:803-433-6796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK RIVER HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 363LF0000X
SC27146261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4400OtherMEDICARE PART B
SC4400Medicare ID - Type UnspecifiedOLANTA MEDICARE NUMBER
SC421836Medicare Oscar/Certification