MEDICARE: CAROLINA ROSES OF BLYTHEWOOD 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	320800000X	Mental Illness Community Based Residential Treatment Facility	123598	SC
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1497290852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA ROSES OF BLYTHEWOOD LLC

Provider Business Mailing Address
First Line	:	PO BOX 942
Second Line	:
City	:	ELGIN
State	:	SC
Zip	:	29045-0942
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 LONG POINTE LN STE 220-T
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29229-7543
Country	:	US
Telephone Number	:	803-397-1937
Fax Number	:	803-735-8112

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SABREEN JOHNSON
Credential	:
Telephone Number	:	803-397-1937

Provider Enumeration Date	:	12/21/2016
Last Update Date	:	04/17/2023

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