Provider Demographics
NPI:1215024401
Name:THI OF SOUTH CAROLINA AT SPARTANBURG, LLC
Entity Type:Organization
Organization Name:THI OF SOUTH CAROLINA AT SPARTANBURG, LLC
Other - Org Name:MAGNOLIA MANOR OF SPARTANBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HILSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-585-0218
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:410-773-1000
Mailing Address - Fax:
Practice Address - Street 1:375 SERPENTINE DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3026
Practice Address - Country:US
Practice Address - Phone:864-585-0218
Practice Address - Fax:864-594-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0867NFMedicaid
425091Medicare Oscar/Certification