Basic Information
Provider Information
NPI: 1437797941
EntityType: 2
ReplacementNPI:  
OrganizationName: CENTER FOR BEHAVIORAL HEALTH SOUTH CAROLINA, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 897
Address2:  
City: BOISE
State: ID
PostalCode: 837010897
CountryCode: US
TelephoneNumber: 2083679021
FaxNumber:  
Practice Location
Address1: 2301 COSGROVE AVE STE F
Address2:  
City: NORTH CHARLESTON
State: SC
PostalCode: 294057663
CountryCode: US
TelephoneNumber: 8435290700
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/16/2019
LastUpdateDate: 12/16/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ROMERO
AuthorizedOfficialFirstName: TONYA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: DIR OF OPERATIONS AND COMPLIANCE
AuthorizedOfficialTelephone: 2083679021
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/16/2019

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM2800X  Y Ambulatory Health Care FacilitiesClinic/CenterMethadone Clinic

No ID Information.


Home