1366503443 NPI number — CHARLESTON ORPHAN HOUSE, INC.

Table of content: (NPI 1366503443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366503443 NPI number — CHARLESTON ORPHAN HOUSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLESTON ORPHAN HOUSE, INC.
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:
CAROLINA YOUTH DEVELOPMENT CENTER
Provider Other Organization Name Type Code:
3
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:
1366503443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5055 LACKAWANNA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29405-4529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-266-5200
Provider Business Mailing Address Fax Number:
843-266-5201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5055 LACKAWANNA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29405-4529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-266-5200
Provider Business Practice Location Address Fax Number:
843-266-5201
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUNCAN
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
KELLEY
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
843-266-5222

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 322D00000X , with the licence number: SR-0008037001-CCI , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 992MXH , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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