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LAKE WYLIE
NPI 1720200884
Assisted Living Facility in Lake Wylie, SC

Active since May 02, 2007CLIA 42D1075596 · Waiver
4877 CHARLOTTE HIGHWAY, LAKE WYLIE, SC 29710(803) 831-9900 Get Directions Write a Review

NPPES record last updated: August 22, 2020. Verified against the NPPES registry weekly; last sync: August 09, 2026.

About Lake Wylie NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

LAKE WYLIE (NPI 1720200884) is a healthcare organization registered as an assisted living facility in Lake Wylie, South Carolina and active in the NPI registry since May 2007. The organization holds a CLIA Waiver certificate valid through October 23, 2027 and lists Jon Harder, President, as its authorized official.

NPPES Registry Identity

NPI1720200884
Entity TypeOrganization
Primary Taxonomy310400000X
Legal Business NameLAKE WYLIE
Location Address4877 CHARLOTTE HIGHWAYLake Wylie, SC 29710
Mailing AddressPo Box 3006Salem, OR 97302 · (503) 485-8697
Phone(803) 831-9900
Organization SubpartNo
Authorized OfficialJon HarderPresident · (503) 486-8697
Enumeration DateMay 2, 2007
Last NPPES UpdateAugust 22, 2020
✔ NPI 1720200884 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyAssisted Living FacilityNursing & Custodial Care Facilities
Taxonomy Code310400000X
Definition
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.
4877 CHARLOTTE HIGHWAY, Lake Wylie, SC 29710
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CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 42D1075596

Lake Wylie Assisted Living Community Lake Wylie Assisted Living LLC Dba · Lake Wylie, SC
Active · expires Oct 23, 2027
CLIA Number42D1075596
Laboratory TypeOther
Certificate Effective DateOctober 24, 2025
Certificate Expiration DateOctober 23, 2027
Laboratory DirectorCheryl Sibert
Laboratory Phone(803) 831-9900
Laboratory LocationLake Wylie Assisted Living Community Lake Wylie Assisted Living LLC Dba4877 Charlotte Hwy, Lake Wylie, SC 29710
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Lake Wylie's NPI number?

The NPI number for Lake Wylie is 1720200884. It was assigned to this organization in the NPPES registry on May 2, 2007.

Where is Lake Wylie located?

Lake Wylie is located at 4877 Charlotte Highway, Lake Wylie, SC 29710. The listed phone number is (803) 831-9900.

What is Lake Wylie's specialty?

The primary specialty registered for this NPI is Assisted Living Facility with taxonomy code 310400000X.

Does Lake Wylie hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 42D1075596) is associated with this NPI, valid through October 23, 2027. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Lake Wylie was last updated on August 22, 2020. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 5 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.