MEDICARE: SOUTH CAROLINA YOUTH ADVOCATE PROGRAM

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

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	:	1790789501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CAROLINA YOUTH ADVOCATE PROGRAM

Provider Business Mailing Address
First Line	:	140 STONERIDGE DR
Second Line	:	STE 350
City	:	COLUMBIA
State	:	SC
Zip	:	29210-8258
Country	:	US
Telephone Number	:	803-779-5500
Fax Number	:	803-779-8444

Provider Business Practice Location Address
First Line	:	140 STONERIDGE DR
Second Line	:	STE 350
City	:	COLUMBIA
State	:	SC
Zip	:	29210-8258
Country	:	US
Telephone Number	:	803-779-5500
Fax Number	:	803-779-8444

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. LEX COLE
Credential	:
Telephone Number	:	803-779-5500

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	06/27/2016

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