Provider Demographics
NPI:1740277359
Name:SOUTH BOSTON MANOR, LLC
Entity type:Organization
Organization Name:SOUTH BOSTON MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:W.
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:SWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-902-4582
Mailing Address - Street 1:406 OAK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1634
Mailing Address - Country:US
Mailing Address - Phone:434-572-2925
Mailing Address - Fax:434-572-8258
Practice Address - Street 1:406 OAK LN
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1634
Practice Address - Country:US
Practice Address - Phone:434-572-2925
Practice Address - Fax:434-572-8258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010053650Medicaid
5110260001Medicare NSC
VA010053650Medicaid