Provider Demographics
NPI:1336246677
Name:ALLENDALE COUNTY HOSPITAL BOARD
Entity Type:Organization
Organization Name:ALLENDALE COUNTY HOSPITAL BOARD
Other - Org Name:JOHN EDWARD HARTER NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-632-3311
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:185 REVOLUTIONARY TRAIL
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-0218
Mailing Address - Country:US
Mailing Address - Phone:803-632-3311
Mailing Address - Fax:803-632-9901
Practice Address - Street 1:185 REVOLUTIONARY TRAIL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827
Practice Address - Country:US
Practice Address - Phone:803-632-3311
Practice Address - Fax:803-632-3415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLENDALE COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF-259314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC118285Medicaid
425103Medicare Oscar/Certification