| Organization Name: | BLACK RIVER HEALTHCARE, INC. |
| NPI Number: | 1558308965 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LESLIE FREEMAN (CREDENTIALING COORDINATOR) |
| Mailing Address: | 86 N Main St Greeleyville |
| State: | SC US |
| Postal Code: | 290569374 |
| Phone Number: | 8434262180 |
| Fax Number: | 8434262182 |
| NPI Enumeration Date: | 06/02/2006 |
| NPI Last Update Date: | 04/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |