1437668019 NPI number — WOODRUFF MANOR

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 1437668019 NPI number — WOODRUFF MANOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODRUFF MANOR
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:
1437668019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29304-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-560-4304
Provider Business Mailing Address Fax Number:
864-569-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1114 E GEORGIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRUFF
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-476-7092
Provider Business Practice Location Address Fax Number:
864-476-0753
Provider Enumeration Date:
09/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MEIKE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
864-560-6000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NF1085 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: UPLN17 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42-5179 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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