Provider Demographics
NPI:1184783284
Name:LITTLE RIVER MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:LITTLE RIVER MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVANGELA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CRISWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-663-1013
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-1013
Mailing Address - Fax:843-663-1017
Practice Address - Street 1:7724 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-3041
Practice Address - Country:US
Practice Address - Phone:843-839-3939
Practice Address - Fax:843-839-3946
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITTLE RIVER MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-06
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QF0400X
SC122300000X, 1041C0700X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC065Medicaid
SCZA9656Medicaid
SCZA9656Medicaid
421889Medicare Oscar/Certification