Provider Demographics
NPI:1306032214
Name:ADJUTANT GENERAL OF SC
Entity Type:Organization
Organization Name:ADJUTANT GENERAL OF SC
Other - Org Name:SC YOUTH CHALLENGE ACADEMY @ CAMP LONG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-331-6675
Mailing Address - Street 1:1 NATIONAL GUARD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-4752
Mailing Address - Country:US
Mailing Address - Phone:803-331-6675
Mailing Address - Fax:
Practice Address - Street 1:5471 LEESBURG RD.
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:SC
Practice Address - Zip Code:29044-9184
Practice Address - Country:US
Practice Address - Phone:803-832-4876
Practice Address - Fax:803-832-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPR38913251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management