=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194231191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITHFUL ADULT DAYCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2017
-----------------------------------------------------
Last Update Date | 12/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 SAINT MATTHEWS RD
-----------------------------------------------------
City | ST MATTHEWS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29135-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-655-5002
-----------------------------------------------------
Fax | 803-655-5001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 SAINT MATTHEWS RD
-----------------------------------------------------
City | ST MATTHEWS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29135-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-655-5002
-----------------------------------------------------
Fax | 803-655-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | BETTYE RAVENELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-655-5002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | ADC-0420
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------