1790078582 NPI number — ADVANTAGE VETERANS SERVICES OF

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790078582 NPI number — ADVANTAGE VETERANS SERVICES OF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE VETERANS SERVICES OF
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VETERANS VICTORY HOUSE NURSING HOME
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790078582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5285
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29623-5285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-224-3898
Provider Business Mailing Address Fax Number:
864-224-3609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2461 SIDNEYS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALTERBORO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29488-6783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-538-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HILLIARD
Authorized Official First Name:
HEYWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT - OPERATIONS
Authorized Official Telephone Number:
864-224-3898

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  9034 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0921NF , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4230291 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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