=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962837104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES A KUYKENDALL LAC CAC II MAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2013
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 WALL ST
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29673-6754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-295-1280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 WALL ST
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29673-6754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-295-1280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1210026
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 331
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------