Provider Demographics
NPI:1427412980
Name:LAURELCREST
Entity Type:Organization
Organization Name:LAURELCREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REHAB
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDENAGEL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:864-544-2323
Mailing Address - Street 1:34 WOODCROSS DR APT 1203
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2365
Mailing Address - Country:US
Mailing Address - Phone:803-719-2206
Mailing Address - Fax:
Practice Address - Street 1:100 JOSEPH WALKER DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6971
Practice Address - Country:US
Practice Address - Phone:803-796-0370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2310302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========8OtherDIRECT BILL