Healthcare Provider Details

I. General information

NPI: 1780657528
Provider Name (Legal Business Name): CHESTERFIELD MARLBORO LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 CHERAW ST
BENNETTSVILLE SC
29512-2466
US

IV. Provider business mailing address

PO BOX 198157
ATLANTA GA
30384-8157
US

V. Phone/Fax

Practice location:
  • Phone: 843-479-2881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License NumberHTL-677
License Number StateSC

VIII. Authorized Official

Name: LAURIE HOLTSFORD
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-465-7466