Provider Demographics
NPI:1407978190
Name:CHESTERFIELD MARLBORO LP
Entity Type:Organization
Organization Name:CHESTERFIELD MARLBORO LP
Other - Org Name:MARLBORO PRIMARY CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:1040 MARLBORO WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-2494
Mailing Address - Country:US
Mailing Address - Phone:843-479-5890
Mailing Address - Fax:843-479-5893
Practice Address - Street 1:1040 MARLBORO WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2494
Practice Address - Country:US
Practice Address - Phone:843-479-5890
Practice Address - Fax:843-479-5893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHESTERFIELD MARLBORO LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC529Medicaid
SCRHC529Medicaid