NPIMap

Organization Active NPI

Little River Medical Center Inc

  • Federally Qualified Health Center (FQHC)
  • Little River, SC
National Provider Identifier
1629021076
Registry record updated May 21, 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
4303 Live Oak Dr
Little River, SC 29566-9138
Phone
(843) 663-8000
Fax
(843) 280-2455
NPI assigned
May 18, 2006
Last updated
May 21, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 21, 2014

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

Authorized official

Name
Pamela R Davis
Title
Ceo
Phone
(843) 663-8001

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary
Family Nurse Practitioner 363LF0000X SC
Clinical Social Worker 1041C0700X SC
Dentist 122300000X SC
Diabetes Educator Registered Nurse 163WD0400X SC
Pharmacist 183500000X SC
Family Medicine Physician 207Q00000X NU

Addresses

Primary practice location

4303 Live Oak Dr
Little River, SC 29566-9138

Mailing address

PO Box 547
Little River, SC 29566-0547
Phone (843) 663-8000

Other identifiers 2

IdentifierTypeStateIssuer
ZA9656MedicaidSC
FQC024MedicaidSC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031215000742 SC Part B Supplier - Clinic/Group Practice 2961309315 Receives reassigned benefits from 104 practitioners
1 other NPI on this enrollment
Practice locations: Little River, SC
O20070416000544 SC Part A Provider - Federally Qualified Health Center (FQHC) 2961309315 Practice locations: Little River, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629021076. Details of each certification follow.

Federally qualified health center certification: CCN 421827

Legal name
LITTLE RIVER MEDICAL CENTER INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 1, 1991
Last certification
Oct 1, 1991
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 9, 1978 in SC
Enrollment address
4303 Live Oak Dr
Little River, SC 29566-9138

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).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

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

Other organizations with this tax ID 25

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

View all 25

Ownership & related parties

All disclosed owners & managing parties 9

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

NameRoleSinceShare
Charles Randall Individual Corporate Director Feb 1, 2011
Sara Donevant Individual OtherBoard Member Jan 1, 2013
William J Oconnor Individual OtherBoard Member Oct 13, 2017
Willie a Hucks Individual OtherBoard Member Feb 1, 2011
Robert Hucks Individual OtherBoard Member Jan 1, 2013
Elouise G Young Individual OtherBoard Member Oct 13, 2017
Cynthia Gause Individual OtherBoard Member Jan 1, 2013
Pamela R Davis Individual Corporate OfficerCeo Nov 6, 2003
Corporate DirectorCeo Nov 6, 2003
W-2 Managing EmployeeCeo Nov 6, 2003
Luz E Kuhler Individual Corporate DirectorMedical Director Feb 1, 2011

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

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 106

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 106

NPI Registry JSON

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

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400630400000",
    "number": "1629021076",
    "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": "843-663-8000",
            "fax_number": "843-663-1017"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4303 LIVE OAK DR",
            "city": "LITTLE RIVER",
            "state": "SC",
            "postal_code": "295669138",
            "telephone_number": "843-663-8000",
            "fax_number": "843-280-2455"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LITTLE RIVER MEDICAL CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-18",
        "last_updated": "2014-05-21",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "PAMELA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "843-663-8001"
    },
    "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": "163WD0400X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Diabetes Educator",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "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": "ZA9656",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC024",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Little River, SC

Sources for this page

Verify at the official NPI Registry.