Provider Demographics
NPI:1497842686
Name:THI OF SOUTH CAROLINA AT MONCKS CORNER, LLC
Entity Type:Organization
Organization Name:THI OF SOUTH CAROLINA AT MONCKS CORNER, LLC
Other - Org Name:MAGNOLIA MANOR - MONCKS CORNER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-8368
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:410-773-1000
Mailing Address - Fax:
Practice Address - Street 1:505 S LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3553
Practice Address - Country:US
Practice Address - Phone:843-761-8368
Practice Address - Fax:843-761-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
425140Medicare ID - Type Unspecified