Basic Information
| Provider Information | |||||||||
| NPI: | 1528496668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVA REHABILITATION AND HEALTHCARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | IVA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296559765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643487433 | ||||||||
| FaxNumber: | 8643483888 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | IVA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296559765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8643487433 | ||||||||
| FaxNumber: | 8643483888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | MEER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6296260000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORIANNA SC OPERATOR HOLDINGS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | NF1049 | 05 | SC | MEDICAID |