=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275848640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN CHILDREN'S HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2010
-----------------------------------------------------
Last Update Date | 08/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 CHILDRENS WAY
-----------------------------------------------------
City | DUNCAN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29334-9769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-439-0259
-----------------------------------------------------
Fax | 864-949-0248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 CHILDRENS WAY
-----------------------------------------------------
City | DUNCAN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29334-9769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-439-0259
-----------------------------------------------------
Fax | 864-949-0248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ROBERT C. KIMBERLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-439-0259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number | LPC 1810
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------