Provider Demographics
NPI:1790842987
Name:VNA OF GREATER BAMBERG, INC.
Entity Type:Organization
Organization Name:VNA OF GREATER BAMBERG, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAVY
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:GWALTNEY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:803-245-5611
Mailing Address - Street 1:923 MIDWAY ST
Mailing Address - Street 2:PO BOX 1048
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1957
Mailing Address - Country:US
Mailing Address - Phone:803-245-5611
Mailing Address - Fax:803-245-3259
Practice Address - Street 1:923 MIDWAY ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1957
Practice Address - Country:US
Practice Address - Phone:803-245-5611
Practice Address - Fax:803-245-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHHA-045251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC427030Medicaid
SC427030Medicaid