Provider Demographics
NPI:1730665761
Name:THE BLAKE RCF
Entity Type:Organization
Organization Name:THE BLAKE RCF
Other - Org Name:THE BLAKE RCF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:NOVELLA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-262-8387
Mailing Address - Street 1:1219 JASPER ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3570
Mailing Address - Country:US
Mailing Address - Phone:803-244-0373
Mailing Address - Fax:803-244-0372
Practice Address - Street 1:1219 JASPER ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3570
Practice Address - Country:US
Practice Address - Phone:803-244-0373
Practice Address - Fax:803-244-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness