=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154117752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE TRIBE OF SOUTH CAROLINA HOME CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2025
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 S MAIN ST STE 1
-----------------------------------------------------
City | WOODRUFF
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29388-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-670-9029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 139 S MAIN ST STE 1
-----------------------------------------------------
City | WOODRUFF
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29388-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-670-9029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. LARRY LAGROON SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-914-6155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------