=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023832821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH CAROLINA MENTOR, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2024
-----------------------------------------------------
Last Update Date | 11/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 SAINT JULIAN PL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-388-5150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6600 FRANCE AVE S STE 350
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-388-5150
-----------------------------------------------------
Fax | 952-922-6885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRES & SR ASST GENERAL COUNSEL
-----------------------------------------------------
Name | MARY PATRICIA RODENBERG-ROBERTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-836-2234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------