MEDICARE: SEACOAST YOUTH ACADEMY

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1699821165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEACOAST YOUTH ACADEMY

Provider Business Mailing Address
First Line	:	6367 BAY RD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-6501
Country	:	US
Telephone Number	:	843-215-8080
Fax Number	:

Provider Business Practice Location Address
First Line	:	6367 BAY RD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-6501
Country	:	US
Telephone Number	:	843-215-8080
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	SHERRI JOHNSON
Credential	:
Telephone Number	:	843-340-0701

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	08/22/2020

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Directions to “SEACOAST YOUTH ACADEMY ” Practice Location

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