Healthcare Provider Details

I. General information

NPI: 1689002263
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 POPE DR
WAMPUM PA
16157-3521
US

IV. Provider business mailing address

4401 BELLE OAKS DR
N CHARLESTON SC
29405-8537
US

V. Phone/Fax

Practice location:
  • Phone: 724-535-3162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5386
License Number StateSC

VIII. Authorized Official

Name: MISS HOLLY MATHIS
Title or Position: STAFFING MANAGER
Credential:
Phone: 866-571-2700