Provider Demographics
NPI:1043291263
Name:CLARENDON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLARENDON MEMORIAL HOSPITAL
Other - Org Name:LAKE MOULTRIE NURSING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-433-2005
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHEN
Mailing Address - State:SC
Mailing Address - Zip Code:29479-1108
Mailing Address - Country:US
Mailing Address - Phone:843-567-2307
Mailing Address - Fax:846-567-2305
Practice Address - Street 1:1038 MCGILL LN
Practice Address - Street 2:
Practice Address - City:SAINT STEPHEN
Practice Address - State:SC
Practice Address - Zip Code:29479-3196
Practice Address - Country:US
Practice Address - Phone:843-567-2307
Practice Address - Fax:843-567-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF738314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0738NFMedicaid
SC0674160004Medicare NSC
425341Medicare ID - Type Unspecified