Provider Demographics
NPI:1134146210
Name:WOODRUFF MANOR, LLC
Entity Type:Organization
Organization Name:WOODRUFF MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:864-476-7092
Mailing Address - Street 1:1114 E GEORGIA RD
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:SC
Mailing Address - Zip Code:29388-9350
Mailing Address - Country:US
Mailing Address - Phone:864-476-7092
Mailing Address - Fax:864-476-0753
Practice Address - Street 1:1114 E GEORGIA RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388-9350
Practice Address - Country:US
Practice Address - Phone:864-476-7092
Practice Address - Fax:864-476-0753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF823314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0823NFMedicaid
SC0823NFMedicaid
SC4691810001Medicare NSC