NPIMap

Organization Active NPI

Clarendon Memorial Hospital

Doing business as Lake Moultrie Health and Rehab Center

  • Skilled Nursing Facility
  • Saint Stephen, SC
National Provider Identifier
1043291263
Registry record updated Feb 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
NCF738 Issued in SC
Legal business name
CLARENDON MEMORIAL HOSPITAL
Doing business as
Lake Moultrie Health and Rehab Center
Lake Moultrie Nursing Facility
Practice address
1038 McGill LN
Saint Stephen, SC 29479-3196
Phone
(843) 567-2307
Fax
(843) 567-2305
NPI assigned
Nov 7, 2005
Last updated
Feb 8, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 8, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Christie H Browder
Title
Cfo
Phone
(803) 433-2005

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NCF738 SC Primary

Addresses

Primary practice location

1038 McGill LN
Saint Stephen, SC 29479-3196

Mailing address

PO Box 1108
Saint Stephen, SC 29479-1108
Phone (843) 567-2307

Other identifiers 1

IdentifierTypeStateIssuer
0738NFMedicaidSC

Other names 2

  • Lake Moultrie Health and Rehab Center Doing business as
  • Lake Moultrie Nursing Facility Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120412000527 SC Part A Provider - Skilled Nursing Facility 4082514948 Practice locations: Saint Stephen, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043291263. Details of each certification follow.

Skilled nursing facility certification: CCN 425341

Legal name
CLARENDON MEMORIAL HOSPITAL
Doing business as
SOUTHERN SENIOR LIVING
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 1, 1995
Last certification
Jan 22, 2025
Beds
88
Ownership / control type
Hospital District
Multi-facility organization
Southern Senior Living
Organization structure
OtherNon-profit
Enrollment address
1038 McGill LN
Saint Stephen, SC 29479-3196
Nursing home name
LAKE MOULTRIE NURSING HOME

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Lake Moultrie Nursing HomeCCN 425341 · All quality measures
Overall star rating
3 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
Government - Hospital district
Certified
May 1, 1995
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
8882.7 residents per day on average
Penalties (3 years)
1Fines totaling $11,196

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory
Tax ID family
Mill Street Family Medi14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Christina Browder Individual Corporate OfficerCfo Jul 12, 2016
Clarendon Memorial Hospital Organization, Manning, SC 5% Or Greater Direct Ownership Interest Sep 30, 2005
Mathew Stanley Individual Corporate DirectorDirector of Operations May 6, 2019
Operational/Managerial ControlDirector of Operations May 6, 2019
Robin Matthews Individual Corporate OfficerCeo Jul 12, 2016
Operational/Managerial ControlCeo Jul 12, 2016

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Southern Senior LivingManning, SC, CCN 425114 Skilled nursing facility 5% Or Greater Direct Ownership Interest Sep 30, 2005
Southern Senior LivingSummerton, SC, CCN 425300 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Sep 30, 2005

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1131321600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644278400000",
    "number": "1043291263",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1108",
            "city": "SAINT STEPHEN",
            "state": "SC",
            "postal_code": "294791108",
            "telephone_number": "843-567-2307",
            "fax_number": "846-567-2305"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1038 MCGILL LN",
            "city": "SAINT STEPHEN",
            "state": "SC",
            "postal_code": "294793196",
            "telephone_number": "843-567-2307",
            "fax_number": "843-567-2305"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLARENDON MEMORIAL HOSPITAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-07",
        "last_updated": "2022-02-08",
        "certification_date": "2022-02-08",
        "status": "A",
        "authorized_official_last_name": "BROWDER",
        "authorized_official_first_name": "CHRISTIE",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "803-433-2005",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "SC",
            "license": "NCF738",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0738NF",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Moultrie Health and Rehab Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lake Moultrie Nursing Facility",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Saint Stephen, SC

Sources for this page

Verify at the official NPI Registry.