Healthcare Provider Details

I. General information

NPI: 1275994022
Provider Name (Legal Business Name): KENNEDY'S ASSISTIVE LIVING AND EDUCATIONAL FACILTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 DECKER BLVD
COLUMBIA SC
29206-3470
US

IV. Provider business mailing address

1941 DECKER BLVD
COLUMBIA SC
29206-3470
US

V. Phone/Fax

Practice location:
  • Phone: 803-787-0020
  • Fax:
Mailing address:
  • Phone: 803-787-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number2016-38336-37480
License Number State
# 7
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROLYN A KENNEDY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: ED.D.
Phone: 803-736-5872