=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811192115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 DAVEGA DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-9698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-772-5885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 DAVEGA DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-9698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-772-5885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. KEVIN JOHNSON
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 803-365-0855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NCF545
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------