Healthcare Provider Details

I. General information

NPI: 1043365703
Provider Name (Legal Business Name): SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HARDEN ST.
COLUMBIA SC
29203-7107
US

IV. Provider business mailing address

2200 HARDEN ST.
COLUMBIA SC
29203-7107
US

V. Phone/Fax

Practice location:
  • Phone: 803-737-5339
  • Fax: 803-737-5436
Mailing address:
  • Phone: 803-737-5339
  • Fax: 803-737-5436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number50-001783
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number50001783
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number50001783
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number50001783
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number50001783
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number50001783
License Number StateSC

VIII. Authorized Official

Name: KIMBERLY BUTTERFLY RUDD
Title or Position: DIRECTOR OF PROFESSIONAL SERVICES
Credential: M.D.
Phone: 803-737-5301