Basic Information
| Provider Information | |||||||||
| NPI: | 1619995370 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH ACCOUNTING OFFICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREENVILLE MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411215 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8038988503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 301100 | 05 | SC | MEDICAID |