Healthcare Provider Details

I. General information

NPI: 1003845983
Provider Name (Legal Business Name): BOYS HOME OF THE SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10612 AUGUSTA RD
BELTON SC
29627-9246
US

IV. Provider business mailing address

10612 AUGUSTA RD
BELTON SC
29627-9246
US

V. Phone/Fax

Practice location:
  • Phone: 864-243-3443
  • Fax: 864-243-5743
Mailing address:
  • Phone: 864-243-3443
  • Fax: 864-243-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSR0008004001
License Number StateSC

VIII. Authorized Official

Name: GLYNDA TAYLOR CADDELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 864-243-3443