1174662134 NPI number — MARLBORO ADULT CARE INC

Table of content: (NPI 1174662134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174662134 NPI number — MARLBORO ADULT CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARLBORO ADULT CARE INC
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:
Provider Other Organization Name Type Code:
6
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:
1174662134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1484
Provider Second Line Business Mailing Address:
1039 CHERAW STREET
Provider Business Mailing Address City Name:
BENNETTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29512-2422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-479-0603
Provider Business Mailing Address Fax Number:
843-479-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1039 CHERAW STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENNETTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29512-2422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-479-0603
Provider Business Practice Location Address Fax Number:
843-479-0081
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
843-479-0603

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  ADC 243 , 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: EX0696 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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