Healthcare Provider Details

I. General information

NPI: 1417420464
Provider Name (Legal Business Name): KEYSTONE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 LA PATOS DR
MYRTLE BEACH SC
29588-8484
US

IV. Provider business mailing address

285 LA PATOS DR
MYRTLE BEACH SC
29588-8484
US

V. Phone/Fax

Practice location:
  • Phone: 191-953-9852
  • Fax:
Mailing address:
  • Phone: 191-953-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. CRYSTAL BUSH
Title or Position: ORGANIZER
Credential: LISW-CP
Phone: 919-539-8520