MEDICARE: NEW DOMINION COMMUNITY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor
4	104100000X	Social Worker
5	1041C0700X	Clinical Social Worker
6	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447654363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW DOMINION COMMUNITY SERVICES LLC

Provider Business Mailing Address
First Line	:	900 GREENVILLE DR
Second Line	:
City	:	WILLIAMSTON
State	:	SC
Zip	:	29697-1130
Country	:	US
Telephone Number	:	864-847-1818
Fax Number	:	678-550-9865

Provider Business Practice Location Address
First Line	:	900 GREENVILLE DRIVE
Second Line	:
City	:	WILLIAMSTON
State	:	SC
Zip	:	29697-0000
Country	:	US
Telephone Number	:	864-847-1818
Fax Number	:	678-550-9865

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. IDRIS TALIB
Credential	:
Telephone Number	:	864-847-1818

Provider Enumeration Date	:	10/21/2014
Last Update Date	:	11/20/2015

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Directions to “NEW DOMINION COMMUNITY SERVICES LLC ” Practice Location

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