Provider Demographics
NPI:1083852511
Name:EXCALIBUR YOUTH SERVICES, LLC.
Entity Type:Organization
Organization Name:EXCALIBUR YOUTH SERVICES, LLC.
Other - Org Name:VENICE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:ISABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-703-2829
Mailing Address - Street 1:PO BOX 18346
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-0968
Mailing Address - Country:US
Mailing Address - Phone:919-703-2829
Mailing Address - Fax:864-294-1774
Practice Address - Street 1:3683 S. INDUSTRIAL DR.
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:864-688-1133
Practice Address - Fax:864-962-6976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRTF-0022323P00000X
323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRTF-0022OtherSOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENT CONTROL
SCRTF055Medicaid