Provider Demographics
NPI:1689761876
Name:THI OF SOUTH CAROLINA AT MAGNOLIA MANORINMAN, LLC
Entity Type:Organization
Organization Name:THI OF SOUTH CAROLINA AT MAGNOLIA MANORINMAN, LLC
Other - Org Name:MAGNOLIA MANOR - INMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-472-9055
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 1:63 BLACKSTOCK RD
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-1835
Practice Address - Country:US
Practice Address - Phone:864-472-9055
Practice Address - Fax:864-472-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0863NFMedicaid
SC0863NFMedicaid