Basic Information
| Provider Information | |||||||||
| NPI: | 1992181812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHP TEGA CAY SC TENANT CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075407652 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 WELLMORE DR | ||||||||
| Address2: | |||||||||
| City: | TEGA CAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297080039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038357000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2015 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | MADDRON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4075407652 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | NCF-0964 | SC | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | NCF-0964 | SC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.