Basic Information
| Provider Information | |||||||||
| NPI: | 1306844196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARNWELL COUNTY COMMISSION ON ALCOHOL AND DRUG ABUSE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AXIS I CENTER OF BARNWELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 179 FULDNER ROAD | ||||||||
| Address2: | |||||||||
| City: | BARNWELL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035411245 | ||||||||
| FaxNumber: | 8035411247 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 FULDNER ROAD | ||||||||
| Address2: | |||||||||
| City: | BARNWELL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035411245 | ||||||||
| FaxNumber: | 8035411247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSH | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8035411245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CSPS, ICPS | ||||||||
| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | AD31BA | 05 | SC | MEDICAID |