Basic Information
| Provider Information | |||||||||
| NPI: | 1922237684 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AGAPE ASSISTED LIVING OF CONWAY, INC, | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2320 HIGHWAY 378 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295274911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433972273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2320 HIGHWAY 378 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295274911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433972273 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | MIDDLETON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8034543505 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | CRC-1453 | SC | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | CRC1453 | 05 | SC | MEDICAID |