Basic Information
| Provider Information | |||||||||
| NPI: | 1053309757 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAUREL BAYE HEALTHCARE OF ORANGEBURG, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 STONEWALL JACKSON BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291157250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035347771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 575 STONEWALL JACKSON BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291157250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035347771 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | TILLER | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8432166800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NCF- 858 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0858NF | 05 | SC | MEDICAID |