Basic Information
| Provider Information | |||||||||
| NPI: | 1407978190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESTERFIELD MARLBORO LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARLBORO PRIMARY CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 MARLBORO WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295122494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434795890 | ||||||||
| FaxNumber: | 8434795893 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MARLBORO WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295122494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434795890 | ||||||||
| FaxNumber: | 8434795893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESTERFIELD MARLBORO LP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC529 | 05 | SC | MEDICAID |