1083755615 NPI number — SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE

Table of content: (NPI 1083755615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083755615 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:
GATEWAYS GROUP HOME
Provider Other Organization Name Type Code:
5
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:
1083755615
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:
806-896-4751
Provider Business Mailing Address Fax Number:
803-896-8473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 SHIVERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-896-9122
Provider Business Practice Location Address Fax Number:
803-896-8476
Provider Enumeration Date:
02/08/2007

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: DJJ056 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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