1083852511 NPI number — EXCALIBUR YOUTH SERVICES, LLC.

Table of content: (NPI 1083852511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083852511 NPI number — EXCALIBUR YOUTH SERVICES, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCALIBUR YOUTH SERVICES, 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:
VENICE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY
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:
1083852511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18346
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60055-0968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-703-2829
Provider Business Mailing Address Fax Number:
864-294-1774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3683 S. INDUSTRIAL DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIMPSONVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-688-1133
Provider Business Practice Location Address Fax Number:
864-962-6976
Provider Enumeration Date:
01/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ISABELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, REVENUE CYCLE
Authorized Official Telephone Number:
919-703-2829

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  RTF-0022 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: RTF-0022 . This is a "SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENT CONTROL" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: RTF055 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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