Provider Demographics
NPI:1609866912
Name:ALLENDALE COUNTY HOSPITAL BOARD
Entity type:Organization
Organization Name:ALLENDALE COUNTY HOSPITAL BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:H
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-632-3311
Mailing Address - Street 1:1787 ALLENDALE FAIRFAX HWY
Mailing Address - Street 2:P. O. BOX 218
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-9133
Mailing Address - Country:US
Mailing Address - Phone:803-632-3311
Mailing Address - Fax:803-632-3415
Practice Address - Street 1:1787 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9133
Practice Address - Country:US
Practice Address - Phone:803-632-3311
Practice Address - Fax:803-632-3415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLENDALE COUNTY HOSPITAL BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-27
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
SCHTL-041282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC100895Medicaid
SC300958Medicaid
SC3389Medicaid
SC=========OtherBCBS AND COMMERCIAL PAYER
SC421300Medicare Oscar/Certification
SC42Z300Medicare Oscar/Certification