Healthcare Provider Details

I. General information

NPI: 1376939520
Provider Name (Legal Business Name): FAMCARE CONNECT OF SOUTH CAROLINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 OLD SALEM RD SE
CONYERS GA
30094-5944
US

IV. Provider business mailing address

107 N OAK ST
SENECA SC
29678-3219
US

V. Phone/Fax

Practice location:
  • Phone: 770-633-8550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSICA LANE
Title or Position: DIRECTOR OF ADMINISTRATION
Credential:
Phone: 770-633-8550