Provider Demographics
NPI:1154303089
Name:TIDELANDS GHS JOINT VENTURE LLC
Entity Type:Organization
Organization Name:TIDELANDS GHS JOINT VENTURE LLC
Other - Org Name:TIDELANDS COMMUNITY HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:DOAR
Authorized Official - Last Name:STALVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-546-3410
Mailing Address - Street 1:2591 N FRASER ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6411
Mailing Address - Country:US
Mailing Address - Phone:843-546-3410
Mailing Address - Fax:843-527-6964
Practice Address - Street 1:2591 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6411
Practice Address - Country:US
Practice Address - Phone:843-546-3410
Practice Address - Fax:843-527-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHPC009251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCHSP007Medicaid
SCHSP007Medicaid