Healthcare Provider Details

I. General information

NPI: 1699087841
Provider Name (Legal Business Name): PETRA HEALTH & REHAB OF MCCORMICK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2010
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HOLIDAY RD
MC CORMICK SC
29835-3429
US

IV. Provider business mailing address

204 HOLIDAY RD
MC CORMICK SC
29835-3429
US

V. Phone/Fax

Practice location:
  • Phone: 864-391-2390
  • Fax: 864-391-2397
Mailing address:
  • Phone: 864-391-2390
  • Fax: 864-391-2397

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: CHRISTOPHER J MURPHY
Title or Position: VICE PRESIDENT
Credential:
Phone: 901-937-7994