Basic Information
| Provider Information | |||||||||
| NPI: | 1861445835 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WIREGRASS HOSPICE OF SOUTH CAROLINA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINDRED HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 BRAWLEY SCHOOL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046642876 | ||||||||
| FaxNumber: | 7046641306 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 E MAIN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293022182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645856500 | ||||||||
| FaxNumber: | 8645856553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | HPC103 | SC | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | HSP083 | 05 | SC | MEDICAID |