Provider Demographics
NPI:1396723771
Name:KIDS CARE MEDICAL
Entity type:Organization
Organization Name:KIDS CARE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-915-0173
Mailing Address - Street 1:POST OFFICE BOX 1196
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528
Mailing Address - Country:US
Mailing Address - Phone:843-915-0173
Mailing Address - Fax:843-410-6364
Practice Address - Street 1:202 SHERWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-915-0173
Practice Address - Fax:843-410-6364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC026544204332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7703904Medicaid
SCDE2406Medicaid
SC7703904Medicaid