MEDICARE: OUTWARD BOUND COMMUNITY SERVICES, LLC

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	251S00000X	Community/Behavioral Health Agency		SC

General Provider Information

NPI Number	:	1568878775
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTWARD BOUND COMMUNITY SERVICES, LLC

Provider Business Mailing Address
First Line	:	2131 WOODRUFF RD STE 2100
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-5959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2131 WOODRUFF RD STE 2100
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-5959
Country	:	US
Telephone Number	:	336-382-9618
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DERRICK MCDOW
Credential	:
Telephone Number	:	336-382-9618

Provider Enumeration Date	:	07/08/2014
Last Update Date	:	07/08/2014

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