Healthcare Provider Details

I. General information

NPI: 1942445051
Provider Name (Legal Business Name): JADE COMMUNITY RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 & 5 CUNNINGTON STREET
CHARLESTON SC
39405
US

IV. Provider business mailing address

POST OFFICE BOX 21877 3 & 5 CUNNINGTON STREET
CHARLESTON SC
29405
US

V. Phone/Fax

Practice location:
  • Phone: 843-853-0299
  • Fax:
Mailing address:
  • Phone: 843-853-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberCRC 1123
License Number StateSC

VIII. Authorized Official

Name: MS. JULIA M. VELASCO
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 843-853-6885