=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588682447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF SOUTH CAROLINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 07/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 S LEMACKS ST
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-4374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-525-5917
-----------------------------------------------------
Fax | 843-521-7621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 S LEMACKS ST
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-4374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-525-5917
-----------------------------------------------------
Fax | 843-521-7621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/HOME HEALTH ADMINISTRATOR
-----------------------------------------------------
Name | MR. LEE A KIRKPATRICK
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 803-576-2916
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HHA-011
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------