Healthcare Provider Details

I. General information

NPI: 1619047974
Provider Name (Legal Business Name): WINDWOOD FARM HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4857 WINDWOOD FARM RD
AWENDAW SC
29429-5951
US

IV. Provider business mailing address

4857 WINDWOOD FARM RD
AWENDAW SC
29429-5951
US

V. Phone/Fax

Practice location:
  • Phone: 843-884-5342
  • Fax: 843-884-1287
Mailing address:
  • Phone: 843-884-5342
  • Fax: 843-884-1287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSR0008106001CCI
License Number StateSC

VIII. Authorized Official

Name: MRS. DEBORAH MCKELVEY
Title or Position: CEO
Credential:
Phone: 843-884-5342