Provider Demographics
NPI:1487219812
Name:AT HOME PROFESSIONAL CARE OF SC LLC
Entity Type:Organization
Organization Name:AT HOME PROFESSIONAL CARE OF SC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:ATALIA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:864-631-1733
Mailing Address - Street 1:1 CHICK SPRINGS RD STE 102A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-4946
Mailing Address - Country:US
Mailing Address - Phone:864-631-1733
Mailing Address - Fax:864-451-7227
Practice Address - Street 1:1 CHICK SPRINGS RD STE 102A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4946
Practice Address - Country:US
Practice Address - Phone:864-631-1733
Practice Address - Fax:864-451-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC251E00000XMedicaid