Healthcare Provider Details

I. General information

NPI: 1982276960
Provider Name (Legal Business Name): MAVIS MANIGAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 ASHLEY PHOSPHATE RD STE 7
NORTH CHARLESTON SC
29418-8586
US

IV. Provider business mailing address

PO BOX 40331
NORTH CHARLESTON SC
29423-0331
US

V. Phone/Fax

Practice location:
  • Phone: 843-608-7041
  • Fax: 843-800-2254
Mailing address:
  • Phone: 843-530-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: