Healthcare Provider Details

I. General information

NPI: 1043394976
Provider Name (Legal Business Name): CAROLINA AUTISM SUPPORTED LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CARRIAGE LN STE 302
CHARLESTON SC
29407-6050
US

IV. Provider business mailing address

4 CARRIAGE LN STE 302
CHARLESTON SC
29407-6050
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-1905
  • Fax: 843-573-1926
Mailing address:
  • Phone: 843-573-1905
  • Fax: 843-573-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateSC

VIII. Authorized Official

Name: MR. PHIL BLEVINS
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 843-573-1905