Healthcare Provider Details

I. General information

NPI: 1316369333
Provider Name (Legal Business Name): PUT-BACK, A NON-PROFIT ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8408 LITTLE JOHN DR
COLUMBIA SC
29209-5600
US

IV. Provider business mailing address

8408 LITTLE JOHN DR
COLUMBIA SC
29209-5600
US

V. Phone/Fax

Practice location:
  • Phone: 803-783-1801
  • Fax: 803-776-8029
Mailing address:
  • Phone: 803-783-1801
  • Fax: 803-776-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. HARRY EUGENE REESE SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 803-479-9238