Provider Demographics
NPI:1902215296
Name:MIRANDA WILLIS ADULT DAY CARE, LLC
Entity Type:Organization
Organization Name:MIRANDA WILLIS ADULT DAY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW, SW-G, CDP
Authorized Official - Phone:803-586-7455
Mailing Address - Street 1:5932 MCMILLIAN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212
Mailing Address - Country:US
Mailing Address - Phone:803-586-7455
Mailing Address - Fax:
Practice Address - Street 1:5932 MCMILLIAN CIRCLE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212
Practice Address - Country:US
Practice Address - Phone:803-586-7455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10532104100000X
261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty