Provider Demographics
NPI:1982276960
Name:MANIGAULT, MAVIS
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:MANIGAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40331
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29423-0331
Mailing Address - Country:US
Mailing Address - Phone:843-530-2411
Mailing Address - Fax:
Practice Address - Street 1:3618 ASHLEY PHOSPHATE RD STE 7
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-8586
Practice Address - Country:US
Practice Address - Phone:843-608-7041
Practice Address - Fax:843-800-2254
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC374U00000X, 385H00000X, 3747P1801X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care