Provider Demographics
NPI:1346547973
Name:ORIGINAL LIFE HOME CARE AGENCY
Entity Type:Organization
Organization Name:ORIGINAL LIFE HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:JOANNA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-718-5682
Mailing Address - Street 1:27 SPINNAKER LANE
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-7210
Mailing Address - Country:US
Mailing Address - Phone:803-718-5682
Mailing Address - Fax:
Practice Address - Street 1:27 SPINNAKER DR
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-7210
Practice Address - Country:US
Practice Address - Phone:803-718-5682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8005253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care