1043320146 NPI number — STATEWIDE OUTREACH PROJECT LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043320146 NPI number — STATEWIDE OUTREACH PROJECT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATEWIDE OUTREACH PROJECT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043320146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2863
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29116-2863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
866-408-8142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
396 SAINT PAUL ST
Provider Second Line Business Practice Location Address:
SUITE 1111 CAROLINA OFFICE BUILDING
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29115-5465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-992-5534
Provider Business Practice Location Address Fax Number:
866-408-8142
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KEITH
Authorized Official First Name:
JUENARRL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE MINISTER
Authorized Official Telephone Number:
843-993-5534

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)