Basic Information
| Provider Information | |||||||||
| NPI: | 1174596936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTERFIELD MARLBORO LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CHESTERFIELD GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 198172 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303848172 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 CHESTERFIELD HWY | ||||||||
| Address2: | |||||||||
| City: | CHERAW | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295207002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435377881 | ||||||||
| FaxNumber: | 8433203470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTH OFFICIA / DIR BUSINESS OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESTERFIELD MARLBORO LP | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | HTL-681 | SC | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.