NPIMap

Organization Active NPI

Little River Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Myrtle Beach, SC
National Provider Identifier
1669535225
Registry record updated Aug 2, 2024
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
1075 Mr. Joe White Ave
Unit 101
Myrtle Beach, SC 29577-5658
Phone
(843) 839-2049
Fax
(843) 839-1857
NPI assigned
Dec 18, 2006
Last updated
Aug 2, 2024By 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 Aug 2, 2024

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
Professional Counselor 101YP2500X SC
Clinical Social Worker 1041C0700X SC
Family Medicine Physician 207Q00000X SC

Addresses

Primary practice location

1075 Mr. Joe White Ave
Unit 101
Myrtle Beach, SC 29577-5658

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
FQC066MedicaidSC

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040127000790 SC Part A Provider - Federally Qualified Health Center (FQHC) 2961309315 Practice locations: Myrtle Beach, SC
O20170601000080 SC Part B Supplier - Clinic/Group Practice 2961309315 Receives reassigned benefits from 75 practitioners
Practice locations: Myrtle Beach, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669535225. Details of each certification follow.

Federally qualified health center certification: CCN 421890

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
1075 Mr Joe White Avenue
Suite 101
Myrtle Beach, SC 29577-3568
Related CCNs
421827

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
42D1007790Little River Medical Center1075 Mr Joe White Avenue, Suite 101, Myrtle Beach, SC 29577Certificate of waiverNov 24, 2027

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

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Renee Kennedy Individual Corporate Director Jun 1, 2018
Kimberlee Masson Individual Corporate Director Nov 1, 2017
Dana Black Individual Corporate Director Jul 1, 2016
Elvira Medina Individual Corporate Director Jul 1, 2021
Willie a Hucks Individual Corporate Director Apr 30, 2007
Nate Rohler Individual Corporate Director Jul 1, 2021
Gregory Thompson Individual Corporate Director Apr 1, 2019
Elouise G Young Individual Corporate Director Apr 30, 2007
Cynthia Gause Individual Corporate Director Jun 1, 2014
Pamela R Davis Individual Corporate OfficerCeo Dec 12, 2001
W-2 Managing EmployeeCeo Dec 12, 2001
Jack Fields Individual Corporate Director Feb 1, 2019
Maurice Jones Individual Corporate Director Mar 1, 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 75

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 75

NPI Registry JSON

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

{
    "created_epoch": "1166400000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722556800000",
    "number": "1669535225",
    "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": "1075 MR. JOE WHITE AVE",
            "address_2": "UNIT 101",
            "city": "MYRTLE BEACH",
            "state": "SC",
            "postal_code": "295775658",
            "telephone_number": "843-839-2049",
            "fax_number": "843-839-1857"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LITTLE RIVER MEDICAL CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LITTLE RIVER MEDICAL CENTER, INC.",
        "enumeration_date": "2006-12-18",
        "last_updated": "2024-08-02",
        "certification_date": "2024-08-02",
        "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": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "SC",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC066",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Myrtle Beach, SC

Sources for this page

Verify at the official NPI Registry.