Provider Demographics
NPI:1174596936
Name:CHESTERFIELD MARLBORO LP
Entity type:Organization
Organization Name:CHESTERFIELD MARLBORO LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTH OFFICIA / DIR BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:PO BOX 198172
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7002
Practice Address - Country:US
Practice Address - Phone:843-537-7881
Practice Address - Fax:843-320-3470
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERFIELD MARLBORO LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-10
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL-681275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42U062Medicare Oscar/Certification