Basic Information
| Provider Information | |||||||||
| NPI: | 1790078582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANTAGE VETERANS SERVICES OF | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VETERANS VICTORY HOUSE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5285 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296235285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642243898 | ||||||||
| FaxNumber: | 8642243609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2461 SIDNEYS RD | ||||||||
| Address2: | |||||||||
| City: | WALTERBORO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294886783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435383000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 03/29/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HILLIARD | ||||||||
| AuthorizedOfficialFirstName: | HEYWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8642243898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 9034 | SC | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0921NF | 05 | SC | MEDICAID | 4230291 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |