Provider Demographics
NPI:1275994022
Name:KENNEDY'S ASSISTIVE LIVING AND EDUCATIONAL FACILTY
Entity Type:Organization
Organization Name:KENNEDY'S ASSISTIVE LIVING AND EDUCATIONAL FACILTY
Other - Org Name:KALEF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:803-736-5872
Mailing Address - Street 1:1941 DECKER BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3470
Mailing Address - Country:US
Mailing Address - Phone:803-787-0020
Mailing Address - Fax:
Practice Address - Street 1:1941 DECKER BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3470
Practice Address - Country:US
Practice Address - Phone:803-787-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X, 251C00000X, 251E00000X, 251S00000X, 252Y00000X, 253Z00000X
2016-38336-37480252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0993Medicaid