Provider Demographics
NPI:1093897639
Name:PALMETTO JOLLEY ACRES OPERATING LLC
Entity Type:Organization
Organization Name:PALMETTO JOLLEY ACRES OPERATING LLC
Other - Org Name:JOLLEY ACRES HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-534-1001
Mailing Address - Street 1:1180 WOLFE TRL
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-7339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1180 WOLFE TRL
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-7339
Practice Address - Country:US
Practice Address - Phone:803-534-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF-0929314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNCF-0929Medicaid
SC425055Medicare Oscar/Certification