Basic Information
| Provider Information | |||||||||
| NPI: | 1497842686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THI OF SOUTH CAROLINA AT MONCKS CORNER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAGNOLIA MANOR - MONCKS CORNER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 505 S LIVE OAK DR | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618368 | ||||||||
| FaxNumber: | 8437615874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNS | ||||||||
| AuthorizedOfficialFirstName: | JIMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8437618368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.