Provider Demographics
NPI:1871533588
Name:ELLENBURG NURSING CENTER, INC.
Entity type:Organization
Organization Name:ELLENBURG NURSING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-226-5054
Mailing Address - Street 1:611 E HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29624-2814
Mailing Address - Country:US
Mailing Address - Phone:864-226-5054
Mailing Address - Fax:864-226-5643
Practice Address - Street 1:611 E HAMPTON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-2814
Practice Address - Country:US
Practice Address - Phone:864-226-5054
Practice Address - Fax:864-226-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF-231314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400001Medicare ID - Type UnspecifiedPROVIDER NUMBER
SC425047Medicare Oscar/Certification