1558576389 NPI number — METRO TREATMENT OF SOUTH CAROLINA

Table of content: (NPI 1558576389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558576389 NPI number — METRO TREATMENT OF SOUTH CAROLINA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO TREATMENT OF SOUTH CAROLINA
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:
GREENVILLE METRO TREATMENT 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:
1558576389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 MAITLAND CENTER PARKWAY
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-4174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-351-7080
Provider Business Mailing Address Fax Number:
407-351-6930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 AIRPORT RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29607-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-234-7952
Provider Business Practice Location Address Fax Number:
864-234-7985
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
407-351-7080

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  OTPN091 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0002X , with the licence number: 50004493 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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