MEDICARE: A DYNASTY HOME CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1881039584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A DYNASTY HOME CARE LLC

Provider Business Mailing Address
First Line	:	136 WESTPORT DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-7122
Country	:	US
Telephone Number	:	803-960-3163
Fax Number	:

Provider Business Practice Location Address
First Line	:	136 WESTPORT DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-7122
Country	:	US
Telephone Number	:	803-960-3163
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DIMETRIUS FLETCHER
Credential	:
Telephone Number	:	803-960-3163

Provider Enumeration Date	:	05/08/2013
Last Update Date	:	05/08/2013

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