MEDICARE: CHILDRENS RECOVERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency	SC0277	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568699833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDRENS RECOVERY CENTER

Provider Business Mailing Address
First Line	:	1801 LEGION ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3113
Country	:	US
Telephone Number	:	843-448-3400
Fax Number	:	843-626-5040

Provider Business Practice Location Address
First Line	:	1801 LEGION ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3113
Country	:	US
Telephone Number	:	843-448-3400
Fax Number	:	843-626-5040

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. NICOLE BANDEL
Credential	:
Telephone Number	:	843-448-3400

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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