=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346547973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORIGINAL LIFE HOME CARE AGENCY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2011
-----------------------------------------------------
Last Update Date | 02/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 SPINNAKER DR
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29180-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-718-5682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 SPINNAKER LANE
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29180-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-718-5682
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | TABITHA JOANNA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-718-5682
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 8005
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------