1871633081 NPI number — SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE

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 1871633081 NPI number — SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
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:
6
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:
1871633081
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:
PO BOX 21069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29221-1069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-896-4751
Provider Business Mailing Address Fax Number:
803-896-8473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1590 EAST CCC ROAD
Provider Second Line Business Practice Location Address:
HIGHWAY 17 SOUTH
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-546-5478
Provider Business Practice Location Address Fax Number:
843-546-5652
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
MIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAID PROJECT ADMINISTRATOR
Authorized Official Telephone Number:
803-896-4751

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DJJ057 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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