1457486474 NPI number — WHITE OAK MANOR INC

Table of content: (NPI 1457486474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457486474 NPI number — WHITE OAK MANOR INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITE OAK MANOR 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:
1457486474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3347
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:
29304-3347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-366-8155
Provider Business Mailing Address Fax Number:
803-366-8158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 EBENEZER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-366-8155
Provider Business Practice Location Address Fax Number:
803-366-8158
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HANEY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
864-327-1162

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NCF-885 , 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: 5260320001 . This is a "NSC MEDICARE ID-PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0459NH , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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