Provider Demographics
NPI:1558308965
Name:BLACK RIVER HEALTHCARE, INC.
Entity Type:Organization
Organization Name:BLACK RIVER HEALTHCARE, INC.
Other - Org Name:BRH - GREELEYVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
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 1:86 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREELEYVILLE
Practice Address - State:SC
Practice Address - Zip Code:29056-9374
Practice Address - Country:US
Practice Address - Phone:843-426-2180
Practice Address - Fax:843-426-2182
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK RIVER HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-02
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363LF0000X
SC985261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4399OtherMEDICARE PART B
SC421834Medicare Oscar/Certification
SC4399Medicare ID - Type UnspecifiedGREELEYVILLE MEDICARE NUM