MEDICARE: TWENTY TWO PACK MANAGEMENT CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1083876742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWENTY TWO PACK MANAGEMENT CORPORATION

Provider Business Mailing Address
First Line	:	1611 CONSTITUTION BLVD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3047
Country	:	US
Telephone Number	:	803-981-6855
Fax Number	:	803-981-5230

Provider Business Practice Location Address
First Line	:	1611 CONSTITUTION BLVD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3047
Country	:	US
Telephone Number	:	803-981-6855
Fax Number	:	803-981-5230

Authorized Official
Title or Position	:	IMTERIM EXECUTIVE DIRECTOR
Name	:	SHAY LINGERFELT
Credential	:
Telephone Number	:	803-981-6855

Provider Enumeration Date	:	06/25/2008
Last Update Date	:	06/25/2008

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