Provider Demographics
NPI:1699808006
Name:CAROLINA RURAL PRACTICE MANAGEMENT, INC.
Entity Type:Organization
Organization Name:CAROLINA RURAL PRACTICE MANAGEMENT, INC.
Other - Org Name:BLACKVILLE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:ALSBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-641-6277
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:22 GARDENER ROAD
Mailing Address - City:BLACKVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29817-0247
Mailing Address - Country:US
Mailing Address - Phone:803-284-2041
Mailing Address - Fax:803-284-5516
Practice Address - Street 1:22 GARDENER RD
Practice Address - Street 2:BOX 247
Practice Address - City:BLACKVILLE
Practice Address - State:SC
Practice Address - Zip Code:29817-0247
Practice Address - Country:US
Practice Address - Phone:803-284-2041
Practice Address - Fax:803-284-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC08504261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC005Medicaid
SC423831Medicare ID - Type UnspecifiedRURAL HEALTH CARE MEDICAR