1265953590 NPI number — CLUB HORIZONS OF CHARLESTON, LLC

Table of content: MRS. CAROLYN SUE KIMBROUGH LMP (NPI 1417095928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265953590 NPI number — CLUB HORIZONS OF CHARLESTON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLUB HORIZONS OF CHARLESTON, LLC
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:
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:
1265953590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 COURTHOUSE SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29501-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8088 RIVERS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29406-9235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-992-2432
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BELISSARY
Authorized Official First Name:
ANN
Authorized Official Middle Name:
SPARKS
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
843-992-2432

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  ADC-0418 , 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)





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