Provider Demographics
NPI:1609342260
Name:LITTLE, DARRYL DWIGHT
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:DWIGHT
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:PAGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29728-1925
Mailing Address - Country:US
Mailing Address - Phone:704-906-1430
Mailing Address - Fax:803-696-4227
Practice Address - Street 1:122 N PEARL ST
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-1925
Practice Address - Country:US
Practice Address - Phone:704-906-1430
Practice Address - Fax:803-696-4227
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC832152879Medicaid