Provider Demographics
NPI:1699969733
Name:BLACK RIVER HEALTHCARE, INC.
Entity type:Organization
Organization Name:BLACK RIVER HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-433-6790
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-0578
Mailing Address - Country:US
Mailing Address - Phone:843-355-1425
Mailing Address - Fax:843-355-1429
Practice Address - Street 1:500 THURGOOD MARSHALL BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556
Practice Address - Country:US
Practice Address - Phone:843-355-1425
Practice Address - Fax:843-355-1429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC999207VX0000X
261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty