Healthcare Provider Details

I. General information

NPI: 1548881972
Provider Name (Legal Business Name): FSL GREENVILLE SC TENANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 PELHAM RD
GREENVILLE SC
29615-3600
US

IV. Provider business mailing address

1240 E INEPENDENCE ST SUITE 200
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-877-1717
  • Fax:
Mailing address:
  • Phone: 417-521-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN FOSTER
Title or Position: MANAGING MEMBER
Credential:
Phone: 417-521-8522