=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669030946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEE DEE KIDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 347 DOVESVILLE HWY
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29540-9366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-230-8824
-----------------------------------------------------
Fax | 877-827-5681
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 607
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29540-0607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-230-8824
-----------------------------------------------------
Fax | 877-827-5681
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/EARLY INTERVENTION SUPERVISOR
-----------------------------------------------------
Name | TCHALLA Y DOUGLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-230-8824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------