MEDICARE: SOUTH BAY AT MT. PLEASANT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1437616414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BAY AT MT. PLEASANT, LLC

Provider Business Mailing Address
First Line	:	1400 LIBERTY MIDTOWN DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3997
Country	:	US
Telephone Number	:	910-642-0224
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 LIBERTY MIDTOWN DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3997
Country	:	US
Telephone Number	:	910-642-0224
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JOSEPH V CALCUTT
Credential	:
Telephone Number	:	910-815-3122

Provider Enumeration Date	:	02/26/2019
Last Update Date	:	03/05/2020

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