Basic Information
| Provider Information | |||||||||
| NPI: | 1265953590 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLUB HORIZONS OF CHARLESTON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 COURTHOUSE SQ | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295013432 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8088 RIVERS AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439922432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BELISSARY | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | SPARKS | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8439922432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.ED. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | ADC-0418 | SC | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.