Healthcare Provider Details

I. General information

NPI: 1619032034
Provider Name (Legal Business Name): RECOVERY CONCEPTS OF CAROLINA UPST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 04/03/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 E MAIN ST
EASLEY SC
29640-3791
US

IV. Provider business mailing address

1653 E MAIN ST
EASLEY SC
29640-3791
US

V. Phone/Fax

Practice location:
  • Phone: 864-306-8533
  • Fax: 864-306-8513
Mailing address:
  • Phone: 864-306-8533
  • Fax: 864-306-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2093317
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: GAJENDRA BAFNA
Title or Position: PIC
Credential: RPH
Phone: 864-306-8533