Healthcare Provider Details

I. General information

NPI: 1720200884
Provider Name (Legal Business Name): LAKE WYLIE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4877 CHARLOTTE HIGHWAY
LAKE WYLIE SC
29710
US

IV. Provider business mailing address

PO BOX 3006
SALEM OR
97302
US

V. Phone/Fax

Practice location:
  • Phone: 803-831-9900
  • Fax:
Mailing address:
  • Phone: 503-485-8697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JON HARDER
Title or Position: PRESIDENT
Credential:
Phone: 503-486-8697