Basic Information
| Provider Information | |||||||||
| NPI: | 1336165810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENVILLE LIVING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 GRACE DR | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296409088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642693725 | ||||||||
| FaxNumber: | 8642953383 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 LAURENS RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642328196 | ||||||||
| FaxNumber: | 8642352919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | SWIFT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8642693725 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NCF-613 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0613 NH | 05 | SC | MEDICAID |