Provider Demographics
NPI:1013114818
Name:RIDGE PEDIATRICS AND ADOLESCENT CENTER
Entity Type:Organization
Organization Name:RIDGE PEDIATRICS AND ADOLESCENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-532-2877
Mailing Address - Street 1:338 E COLUMBIA AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-9285
Mailing Address - Country:US
Mailing Address - Phone:803-532-2877
Mailing Address - Fax:803-532-5430
Practice Address - Street 1:338 E COLUMBIA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-9285
Practice Address - Country:US
Practice Address - Phone:803-532-2877
Practice Address - Fax:803-532-5430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3903Medicaid
SCGP3903Medicaid