=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902346273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXIMUS SPARTANBURG, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2017
-----------------------------------------------------
Last Update Date | 03/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 SKYLYN DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29307-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-208-1844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 SKYLYN DR
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29307-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-208-1844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | HENRY STEINMETZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-220-2061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NCF-0700
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------