Healthcare Provider Details

I. General information

NPI: 1790789501
Provider Name (Legal Business Name): SOUTH CAROLINA YOUTH ADVOCATE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 STONERIDGE DR STE 350
COLUMBIA SC
29210-8258
US

IV. Provider business mailing address

140 STONERIDGE DR STE 350
COLUMBIA SC
29210-8258
US

V. Phone/Fax

Practice location:
  • Phone: 803-779-5500
  • Fax: 803-779-8444
Mailing address:
  • Phone: 803-779-5500
  • Fax: 803-779-8444

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. LEX COLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 803-779-5500