Provider Demographics
NPI:1346634904
Name:GIBSON-DALTON, CHERYL RENEE (PRESIDENT AND CEO)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:RENEE
Last Name:GIBSON-DALTON
Suffix:
Gender:F
Credentials:PRESIDENT AND CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 EUTAW ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3529
Mailing Address - Country:US
Mailing Address - Phone:803-531-6534
Mailing Address - Fax:803-531-6534
Practice Address - Street 1:1231 EUTAW ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3529
Practice Address - Country:US
Practice Address - Phone:803-531-6534
Practice Address - Fax:803-531-6534
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRC1447311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCRC1447OtherMEDICAID OSS