Healthcare Provider Details

I. General information

NPI: 1447482609
Provider Name (Legal Business Name): KENNEDY'S ASSISTIVE LIVING & EDUCATIONAL FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 SCOTSMAN RD STE 13
COLUMBIA SC
29223-1812
US

IV. Provider business mailing address

3031 SCOTSMAN RD STE 13
COLUMBIA SC
29223-1812
US

V. Phone/Fax

Practice location:
  • Phone: 803-736-5872
  • Fax: 803-736-5872
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number2009-38336-37480
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROLYN ANN KENNEDY
Title or Position: PRESIDENT
Credential:
Phone: 803-736-9151