MEDICARE: CARLYLE SENIOR CARE OF FOUNTAIN INN,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417961715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLYLE SENIOR CARE OF FOUNTAIN INN,LLC

Provider Business Mailing Address
First Line	:	501 GULLIVER ST
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-2105
Country	:	US
Telephone Number	:	864-862-2554
Fax Number	:	864-862-9702

Provider Business Practice Location Address
First Line	:	501 GULLIVER ST
Second Line	:
City	:	FOUNTAIN INN
State	:	SC
Zip	:	29644-2105
Country	:	US
Telephone Number	:	864-862-2554
Fax Number	:	864-862-9702

Authorized Official
Title or Position	:	CEO
Name	:	MR. RICHARD S CRANFORD
Credential	:
Telephone Number	:	843-799-0756

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	02/10/2026

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