Provider Demographics
NPI:1598019341
Name:BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC.
Other - Org Name:ESTILL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-987-7400
Mailing Address - Street 1:721 N OKATIE HWY # 170
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-8276
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:843-987-7498
Practice Address - Street 1:776 2ND ST E
Practice Address - Street 2:
Practice Address - City:ESTILL
Practice Address - State:SC
Practice Address - Zip Code:29918-4926
Practice Address - Country:US
Practice Address - Phone:803-625-2548
Practice Address - Fax:803-625-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCGP2554261QC1500X
SC295441261QD0000X
SCFQC101261QF0400X, 261QM2500X
SCCBP005261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC101Medicaid
SCFQC101Medicaid