Basic Information
| Provider Information | |||||||||
| NPI: | 1568631695 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH CAROLINA DEPT OF MENTAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | C M TUCKER JR NURSING CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 485 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292020485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038988405 | ||||||||
| FaxNumber: | 8038988526 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 HARDEN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292037107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038988405 | ||||||||
| FaxNumber: | 8038988526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 06/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRIER | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8038984802 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NCF334 | SC | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.