Healthcare Provider Details

I. General information

NPI: 1417989229
Provider Name (Legal Business Name): CAROLINA LONG TERM CARE ASSOICATES,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WILDWOOD DR
BELTON SC
29627-9687
US

IV. Provider business mailing address

PO BOX 846
BELTON SC
29627-0846
US

V. Phone/Fax

Practice location:
  • Phone: 864-940-9701
  • Fax: 864-338-8760
Mailing address:
  • Phone: 864-940-9701
  • Fax: 864-338-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH BRYAN HELLER
Title or Position: PRESIDENT
Credential: MD
Phone: 864-940-9701