Provider Demographics
NPI:1043320146
Name:STATEWIDE OUTREACH PROJECT LLC
Entity Type:Organization
Organization Name:STATEWIDE OUTREACH PROJECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MINISTER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUENARRL
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN
Authorized Official - Phone:843-993-5534
Mailing Address - Street 1:PO BOX 2863
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-2863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:866-408-8142
Practice Address - Street 1:396 SAINT PAUL ST
Practice Address - Street 2:SUITE 1111 CAROLINA OFFICE BUILDING
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-5465
Practice Address - Country:US
Practice Address - Phone:888-992-5534
Practice Address - Fax:866-408-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty