Provider Demographics
NPI:1275848640
Name:SOUTHEASTERN CHILDREN'S HOME, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN CHILDREN'S HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KIMBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-439-0259
Mailing Address - Street 1:115 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9769
Mailing Address - Country:US
Mailing Address - Phone:864-439-0259
Mailing Address - Fax:864-949-0248
Practice Address - Street 1:115 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-9769
Practice Address - Country:US
Practice Address - Phone:864-439-0259
Practice Address - Fax:864-949-0248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLPC 1810251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1104977735Medicaid
SC1982634721Medicaid