Basic Information
| Provider Information | |||||||||
| NPI: | 1598256711 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALHOUN COUNTY HIGH SCHOOL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3310 MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291151466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035316900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 SAINTS AVE | ||||||||
| Address2: | |||||||||
| City: | ST MATTHEWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291359005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038743071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2018 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUNSON | ||||||||
| AuthorizedOfficialFirstName: | LEON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8035316900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.