Provider Demographics
NPI:1235569658
Name:SUPPLEMENTAL HEALTH CARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFFING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-571-2700
Mailing Address - Street 1:3462 HIGHWAY 418
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-4829
Mailing Address - Country:US
Mailing Address - Phone:864-640-9294
Mailing Address - Fax:
Practice Address - Street 1:106 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2652
Practice Address - Country:US
Practice Address - Phone:864-681-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6957261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center