Provider Demographics
NPI:1043394976
Name:CAROLINA AUTISM SUPPORTED LIVING SERVICES
Entity type:Organization
Organization Name:CAROLINA AUTISM SUPPORTED LIVING SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:843-573-1905
Mailing Address - Street 1:4 CARRIAGE LN STE 302
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6050
Mailing Address - Country:US
Mailing Address - Phone:843-573-1905
Mailing Address - Fax:843-573-1926
Practice Address - Street 1:4 CARRIAGE LN STE 302
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6050
Practice Address - Country:US
Practice Address - Phone:843-573-1905
Practice Address - Fax:843-573-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD1600X
SC322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC905MXHMedicaid
SCEXG302Medicaid
SC894MXHMedicaid