Provider Demographics
NPI:1902190473
Name:PROFESSIONAL CARE OF MANNING, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CARE OF MANNING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-435-9681
Mailing Address - Street 1:PO BOX 285
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-0285
Mailing Address - Country:US
Mailing Address - Phone:803-435-4301
Mailing Address - Fax:803-435-4346
Practice Address - Street 1:220 WEST BOYCE ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102
Practice Address - Country:US
Practice Address - Phone:803-435-4301
Practice Address - Fax:803-435-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0887Medicaid