Provider Demographics
NPI:1710293873
Name:CLARENDON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLARENDON MEMORIAL HOSPITAL
Other - Org Name:DR. J. DAULTON DUBOSE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMMUNITY CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-435-5270
Mailing Address - Street 1:1056 FELTON ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-7169
Mailing Address - Country:US
Mailing Address - Phone:803-488-9355
Mailing Address - Fax:803-488-9358
Practice Address - Street 1:1056 FELTON ST
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148-7169
Practice Address - Country:US
Practice Address - Phone:803-488-9355
Practice Address - Fax:803-488-9358
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARENDON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC423441Medicare Oscar/Certification