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General NPI Number Information
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NPI Number | 1902215296
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Entity Type | Organization
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Legal Business Name | MIRANDA WILLIS ADULT DAY CARE, LLC
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Dates
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Enumeration Date | 08/12/2014
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 5932 MCMILLIAN CIRCLE
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City | COLUMBIA
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State | SC
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Zip | 29212
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Country | US
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Telephone | 803-586-7455
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Fax |
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Provider Business Mailing Address
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Address Line | 5932 MCMILLIAN CIRCLE
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City | COLUMBIA
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State | SC
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Zip | 29212
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Country | US
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Telephone | 803-586-7455
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MS. CRYSTAL M WILLIS
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Credential | LBSW, SW-G, CDP
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Telephone | 803-586-7455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 10532
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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