Healthcare Provider Details

I. General information

NPI: 1467004705
Provider Name (Legal Business Name): GOOD SAMARITAN ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 KINDALE PARK RD
KINGSTREE SC
29556-5182
US

IV. Provider business mailing address

473 KINDALE PARK RD
KINGSTREE SC
29556-5182
US

V. Phone/Fax

Practice location:
  • Phone: 843-382-2966
  • Fax: 843-382-2298
Mailing address:
  • Phone: 843-382-2966
  • Fax: 843-382-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE ANN PENDERGRASS
Title or Position: OWNER
Credential:
Phone: 843-382-2966