Provider Demographics
NPI:1447482609
Name:KENNEDY'S ASSISTIVE LIVING & EDUCATIONAL FACILITY
Entity type:Organization
Organization Name:KENNEDY'S ASSISTIVE LIVING & EDUCATIONAL FACILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-736-9151
Mailing Address - Street 1:3031 SCOTSMAN RD STE 13
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3031 SCOTSMAN RD STE 13
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1812
Practice Address - Country:US
Practice Address - Phone:803-736-5872
Practice Address - Fax:803-736-5872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2009-38336-37480251C00000X
332B00000X, 332BC3200X, 332BN1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC174H00000XMedicaid
SC374K00000XMedicaid
SC164W00000XMedicaid
SC376J00000XMedicaid
SC385H00000XMedicaid
SC163W00000XMedicaid
SC172V00000XMedicaid
SC347C00000XMedicaid
SC343900000XMedicaid
SC374U00000XMedicaid
SC372500000XMedicaid
SC193200000XMedicaid
SC372600000XMedicaid
SC373H00000XMedicaid
SC390200000XMedicaid