Provider Demographics
NPI:1518658970
Name:BEACON OF LIFE SC LLC
Entity type:Organization
Organization Name:BEACON OF LIFE SC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CZERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-801-2653
Mailing Address - Street 1:106 W MOORE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115
Mailing Address - Country:US
Mailing Address - Phone:732-806-3205
Mailing Address - Fax:
Practice Address - Street 1:2801 ASHLEY PHOSPHATE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-4402
Practice Address - Country:US
Practice Address - Phone:855-801-2653
Practice Address - Fax:732-806-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization