NPIMap

Organization Active NPI

Little River Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Myrtle Beach, SC
National Provider Identifier
1184783284
Registry record updated Dec 9, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
LITTLE RIVER MEDICAL CENTER, INC.
Practice address
7724 N Kings Hwy
Myrtle Beach, SC 29572-3041
Phone
(843) 839-3939
Fax
(843) 839-3946
NPI assigned
Dec 6, 2006
Last updated
Dec 9, 2014By the provider in NPPES
Organization subpart
Yes
Parent organization
LITTLE RIVER MEDICAL CENTER, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 9, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Avangela Kay Criswell
Title
Business Office Director
Phone
(843) 663-1013

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Nurse Practitioner 363LF0000X SC
Clinical Social Worker 1041C0700X SC
Dentist 122300000X SC
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

7724 N Kings Hwy
Myrtle Beach, SC 29572-3041

Mailing address

PO Box 547
Little River, SC 29566-0547
Phone (843) 663-1013

Other identifiers 2

IdentifierTypeStateIssuer
FQC065MedicaidSC
ZA9656MedicaidSC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20040127000916 SC Part A Provider - Federally Qualified Health Center (FQHC) 2961309315 Practice locations: Myrtle Beach, SC
O20100729000883 SC Part A Provider - Federally Qualified Health Center (FQHC) 2961309315 Practice locations: Myrtle Beach, SC
O20170523000231 SC Part B Supplier - Clinic/Group Practice 2961309315 Receives reassigned benefits from 79 practitioners
Practice locations: Myrtle Beach, SC

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1184783284. Details of each certification follow.

Federally qualified health center certification: CCN 421889

Legal name
LITTLE RIVER MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 30, 2004
Last certification
Jan 30, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 9, 1978 in SC
Enrollment address
7724 N Kings Hwy
Myrtle Beach, SC 29572-3041
Related CCNs
421827

Federally qualified health center certification: CCN 421937

Legal name
LITTLE RIVER MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 30, 2010
Last certification
Jun 30, 2010
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 1, 1978 in SC
Enrollment address
7724 N Kings Hwy
Myrtle Beach, SC 29572-3041

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D0995519Little River Medical Center7724 N Kings Hwy, Myrtle Beach, SC 29572Provider-performed microscopyJan 22, 2028

National Provider Directory

National Provider Directory
Tax ID family
Little River Medical Center26 organizations share this tax ID, including this one
Part of
Little River Medical Center

Other organizations with this tax ID 25

Organizations that report the same tax identification number in the National Provider Directory.

View all 25

Locations

7724 N Kings Hwy
Myrtle Beach, SC 29572
Phone (843) 839-3939

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Willie a Hucks Individual Corporate DirectorBoard Member Apr 24, 2007
W-2 Managing Employee Feb 1, 2011
Other Feb 1, 2011
Elouise G Young Individual Corporate DirectorBoard Member Apr 24, 2007
W-2 Managing Employee Feb 1, 2011
Other Feb 1, 2011
Pamela R Davis Individual Corporate OfficerCeo/Board Member Feb 1, 2011
W-2 Managing EmployeeCeo/Board Member Dec 17, 2001
Operational/Managerial ControlCeo/Board Member Feb 1, 2011 100%
Corporate Officer Nov 21, 2012
W-2 Managing Employee Nov 21, 2012

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Little River Medical Center IncAynor, SC, CCN 421133 Federally qualified health center Operational/Managerial Control Dec 1, 2025

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 80

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 80

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165363200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1418083200000",
    "number": "1184783284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 547",
            "city": "LITTLE RIVER",
            "state": "SC",
            "postal_code": "295660547",
            "telephone_number": "843-663-1013",
            "fax_number": "843-663-1017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7724 N KINGS HWY",
            "city": "MYRTLE BEACH",
            "state": "SC",
            "postal_code": "295723041",
            "telephone_number": "843-839-3939",
            "fax_number": "843-839-3946"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LITTLE RIVER MEDICAL CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LITTLE RIVER MEDICAL CENTER, INC.",
        "enumeration_date": "2006-12-06",
        "last_updated": "2014-12-09",
        "status": "A",
        "authorized_official_last_name": "CRISWELL",
        "authorized_official_first_name": "AVANGELA",
        "authorized_official_middle_name": "KAY",
        "authorized_official_title_or_position": "BUSINESS OFFICE DIRECTOR",
        "authorized_official_telephone_number": "843-663-1013",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC065",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZA9656",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Myrtle Beach, SC

Sources for this page

Verify at the official NPI Registry.