Provider Demographics
NPI:1740504869
Name:MIMS, RIDGILL LONG (RN)
Entity type:Individual
Prefix:MRS
First Name:RIDGILL
Middle Name:LONG
Last Name:MIMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-544-4098
Mailing Address - Fax:843-454-0635
Practice Address - Street 1:1324 COMMERECE DR.
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536
Practice Address - Country:US
Practice Address - Phone:843-774-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207106163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid