Provider Demographics
NPI:1700867223
Name:GRAND STRAND SENIOR HEALTH CENTER LLC
Entity Type:Organization
Organization Name:GRAND STRAND SENIOR HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:842-692-1104
Mailing Address - Street 1:4237 RIVER HILLS DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-6444
Mailing Address - Country:US
Mailing Address - Phone:843-281-2778
Mailing Address - Fax:843-281-2785
Practice Address - Street 1:4237 RIVER HILLS DR
Practice Address - Street 2:SUITE 150
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6444
Practice Address - Country:US
Practice Address - Phone:843-281-2778
Practice Address - Fax:843-281-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3814Medicaid
SCGP3814Medicaid
DB4131Medicare PIN