Provider Demographics
NPI:1477546182
Name:BLACKVILLE HEALTHCARE AND REHAB, LLC
Entity Type:Organization
Organization Name:BLACKVILLE HEALTHCARE AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HAIM
Authorized Official - Middle Name:CY
Authorized Official - Last Name:PIZAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-454-9096
Mailing Address - Street 1:1612 JONES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BLACKVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29817-3066
Mailing Address - Country:US
Mailing Address - Phone:803-284-4313
Mailing Address - Fax:803-284-1746
Practice Address - Street 1:1612 JONES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BLACKVILLE
Practice Address - State:SC
Practice Address - Zip Code:29817-3066
Practice Address - Country:US
Practice Address - Phone:803-284-4313
Practice Address - Fax:803-284-1746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-27
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNH-755314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNCF-1038OtherDHEC LIC #
SC0755NFMedicaid
SC0755NFMedicaid