Provider Demographics
NPI:1508152364
Name:DILLON ADULT DAY CARE LLC
Entity Type:Organization
Organization Name:DILLON ADULT DAY CARE LLC
Other - Org Name:DILLON ADULT DAY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-453-1435
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:SC
Mailing Address - Zip Code:29567-0253
Mailing Address - Country:US
Mailing Address - Phone:843-487-5043
Mailing Address - Fax:843-841-0942
Practice Address - Street 1:106 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2850
Practice Address - Country:US
Practice Address - Phone:843-487-5040
Practice Address - Fax:843-487-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCEX0680251E00000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0680Medicaid