Healthcare Provider Details

I. General information

NPI: 1144253824
Provider Name (Legal Business Name): THREE RIVERS RESIDENTIAL TREATMENT MIDLANDS CAMPUS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ERMINE RD
WEST COLUMBIA SC
29170-2024
US

IV. Provider business mailing address

200 ERMINE RD
WEST COLUMBIA SC
29170-2024
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-9918
  • Fax: 803-926-5925
Mailing address:
  • Phone: 803-791-9918
  • Fax: 803-926-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberRTC-018
License Number StateSC

VIII. Authorized Official

Name: JOELLE L VINCENT
Title or Position: BOD
Credential:
Phone: 843-851-5208