Healthcare Provider Details

I. General information

NPI: 1083852511
Provider Name (Legal Business Name): EXCALIBUR YOUTH SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3683 S. INDUSTRIAL DR.
SIMPSONVILLE SC
29681
US

IV. Provider business mailing address

PO BOX 18346
PALATINE IL
60055-0968
US

V. Phone/Fax

Practice location:
  • Phone: 864-688-1133
  • Fax: 864-962-6976
Mailing address:
  • Phone: 919-703-2829
  • Fax: 864-294-1774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberRTF-0022
License Number StateSC

VIII. Authorized Official

Name: ISABELLE WILLIAMS
Title or Position: MANAGER, REVENUE CYCLE
Credential:
Phone: 919-703-2829