Provider Demographics
NPI:1003845983
Name:BOYS HOME OF THE SOUTH
Entity Type:Organization
Organization Name:BOYS HOME OF THE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLYNDA
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:CADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-243-3443
Mailing Address - Street 1:10612 AUGUSTA RD
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:SC
Mailing Address - Zip Code:29627-9246
Mailing Address - Country:US
Mailing Address - Phone:864-243-3443
Mailing Address - Fax:864-243-5743
Practice Address - Street 1:10612 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:SC
Practice Address - Zip Code:29627-9246
Practice Address - Country:US
Practice Address - Phone:864-243-3443
Practice Address - Fax:864-243-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR0008004001322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC968MXHMedicaid