Basic Information
| Provider Information | |||||||||
| NPI: | 1568476885 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH CAROLINA DEPT OF MENTAL HEALTH ACCOUNTING OFFICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATAWBA MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 448 LAKESHORE PKWY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297304264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033289600 | ||||||||
| FaxNumber: | 8033297141 | ||||||||
| Practice Location | |||||||||
| Address1: | 448 LAKESHORE PKWY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297304264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033289600 | ||||||||
| FaxNumber: | 8033297141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8038988503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH | ||||||||
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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 | 342725 | 05 | SC | MEDICAID |