Provider Demographics
NPI:1023078144
Name:EVENING PILOT CLUB OF SUMTER FOUNDATION, INC.
Entity type:Organization
Organization Name:EVENING PILOT CLUB OF SUMTER FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:VERLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HABBERSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-469-8169
Mailing Address - Street 1:PMB #3
Mailing Address - Street 2:1089-A ALICE DRIVE
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:803-469-8169
Mailing Address - Fax:803-469-7140
Practice Address - Street 1:940 SHADOW TRAIL
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2351
Practice Address - Country:US
Practice Address - Phone:803-469-8169
Practice Address - Fax:803-469-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1158Medicaid