Provider Demographics
NPI:1811020183
Name:CAROLINA RURAL PRACTICE MANAGEMENT, INC.
Entity Type:Organization
Organization Name:CAROLINA RURAL PRACTICE MANAGEMENT, INC.
Other - Org Name:WAGENER 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 98
Mailing Address - Street 2:120 LOUIE ST
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164-0098
Mailing Address - Country:US
Mailing Address - Phone:803-564-6497
Mailing Address - Fax:803-564-6498
Practice Address - Street 1:120 LOUIE STREET
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164-0098
Practice Address - Country:US
Practice Address - Phone:803-564-6497
Practice Address - Fax:803-564-6498
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
SCRHC025Medicaid
SCRHC025Medicaid