Provider Demographics
NPI:1912216565
Name:CCC OF FAIR PLAY,LLC
Entity Type:Organization
Organization Name:CCC OF FAIR PLAY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-203-0210
Mailing Address - Street 1:207 FARM HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:FAIR PLAY
Mailing Address - State:SC
Mailing Address - Zip Code:29643-2207
Mailing Address - Country:US
Mailing Address - Phone:864-972-1072
Mailing Address - Fax:
Practice Address - Street 1:207 FARM HOUSE LN
Practice Address - Street 2:
Practice Address - City:FAIR PLAY
Practice Address - State:SC
Practice Address - Zip Code:29643-2207
Practice Address - Country:US
Practice Address - Phone:864-972-1072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCRC1041310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility