Provider Demographics
NPI:1417961715
Name:CARLYLE SENIOR CARE OF FOUNTAIN INN,LLC
Entity Type:Organization
Organization Name:CARLYLE SENIOR CARE OF FOUNTAIN INN,LLC
Other - Org Name:FOUNTAIN INN NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:CRANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-862-2554
Mailing Address - Street 1:501 GULLIVER ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-2105
Mailing Address - Country:US
Mailing Address - Phone:864-862-2554
Mailing Address - Fax:864-862-9702
Practice Address - Street 1:501 GULLIVER ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-2105
Practice Address - Country:US
Practice Address - Phone:864-862-2554
Practice Address - Fax:864-862-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC314000000X, 314000000X
SC1010040001332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0626NHMedicaid
SC0626NHMedicaid
SC1010040001Medicare NSC