Healthcare Provider Details

I. General information

NPI: 1710063375
Provider Name (Legal Business Name): EXCALIBUR YOUTH SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5321 OLD BUNCOMBE RD
GREENVILLE SC
29609-0910
US

IV. Provider business mailing address

PO BOX 968
MARIETTA SC
29661-0968
US

V. Phone/Fax

Practice location:
  • Phone: 864-679-0023
  • Fax: 864-294-1774
Mailing address:
  • Phone: 864-679-0023
  • Fax: 864-294-1774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSR-0009711001-CCI
License Number StateSC

VIII. Authorized Official

Name: MR. MARVIN J. SHORT III
Title or Position: MEMBER
Credential:
Phone: 864-679-0023