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General NPI Number Information
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NPI Number | 1942445051
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Entity Type | Organization
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Legal Business Name | JADE COMMUNITY RESIDENTIAL CARE LLC
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Dates
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Enumeration Date | 12/04/2008
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Last Update Date | 12/04/2008
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Provider Practice Location Address
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Address Line | 3 & 5 CUNNINGTON STREET
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City | CHARLESTON
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State | SC
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Zip | 39405
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Country | US
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Telephone | 843-853-0299
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Fax |
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Provider Business Mailing Address
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Address Line | POST OFFICE BOX 21877 3 & 5 CUNNINGTON STREET
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City | CHARLESTON
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State | SC
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Zip | 29405
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Country | US
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Telephone | 843-853-0299
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | MS. JULIA M. VELASCO
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Credential |
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Telephone | 843-853-6885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | CRC 1123
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License Number State | SC
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