Provider Demographics
NPI:1710161575
Name:PILOT CLUB OF ORANGEBURG FOUNDATION
Entity Type:Organization
Organization Name:PILOT CLUB OF ORANGEBURG FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDATION MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAIGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-534-1717
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:PILOT CLUB OF ORANGEBURG FOUNDATION
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-2282
Mailing Address - Country:US
Mailing Address - Phone:803-534-1717
Mailing Address - Fax:803-543-1877
Practice Address - Street 1:161 CENTER ST
Practice Address - Street 2:PILOT CLUB OF ORANGEBURG FOUNDATION
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-534-1717
Practice Address - Fax:803-534-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1174Medicaid