Provider Demographics
NPI:1992077424
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:C.E.O.
Authorized Official - Prefix:
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:803-433-6790
Mailing Address - Fax:803-433-6796
Practice Address - Street 1:11 W. HOSPITAL ST.
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2925
Practice Address - Country:US
Practice Address - Phone:803-433-4321
Practice Address - Fax:803-433-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty